Hitting the target, missing the point, and losing the plot – A snapshot of the themes arising from the Mid Staffordshire Public Inquiry

There is much anticipation and expectation for Robert Francis QC’s report into the Mid Staffordshire Inquiry. The latest announcement of delay in the issuing of the report (which is now due in early January) means that it will not live up to its previous billing by the Health Service Journal as “the most important NHS event of 2012”, but it could well make it the headline act of 2013.

The Inquiry’s terms of reference require it to identify how “failing and potentially failing hospitals or their services” are identified as early as possible.  However, it seems clear that the lessons in terms of internal governance and interaction with, and between, commissioning, regulatory and oversight bodies are ones which will be applicable to all providers of NHS services.  Equally, the features of good governance which will emerge from the Inquiry are likely to provide valuable learning beyond the NHS and across the entire health and social care sector.

Whilst the Inquiry’s detailed findings and recommendations are awaited, an examination of the evidence identifies a range of themes to which the sector should have regard in anticipation of the final report and beyond.

The volume of evidence is extensive: 139 days of oral evidence and submissions and a further 125 statements read into the record.  There are clearly vast areas for Robert Francis to consider, and it is impossible to seek to summarise these in this article.  But, as an attempt at a ‘snapshot’ summary, you could do worse than reference the two quotes alluded to in the title of this article:

David Flory referred in his evidence to the Inquiry to the possibility that an organisation could “hit the target but miss the point”. The comment related directly to instances of ‘gaming’ where providers focus simply on meeting targets (around clinical activity) rather than on the underlying quality of care delivered.  It could also, perhaps, be taken to apply to targets for financial performance.  Further still, the phrase may be applicable to aspects of the regulatory and supervisory structures at the time which were founded to a larger extent on self-assessment, and reassurance based on the existence of systems and processes rather than on the success of their implementation, outcomes, and patient experience. As Tom Kark QC, Counsel to the Inquiry, stated in his closing submissions: “whilst the Trust management put in place written policies which ticked the right boxes in terms of outside scrutiny, those policies did not translate into a healthy culture.”

Reflecting on the episode recently at the RCGP conference, Sir David Nicholson accepted that the leadership of the NHS at the time had ‘lost the plot’.  He stated “We had a gross deficit of £1billion, a reforming government, a PM committed to change. … We’d lost the reason why we were there: to improve quality and outcomes”. It should be remembered that the difficulties at Mid Staffordshire occurred against a backdrop of extreme financial pressures in the NHS, lack of continuity caused by the re-organisation of the supervisory and commissioning bodies (the rationalising of PCTs and SHAs in 2006), and with a provider focussed on achieving foundation trust status.  It is the resonance of these issues with those currently facing the sector which heightens the importance of the Inquiry report still further.

Quality

The single most important lesson to emerge from the examination of the events at Stafford is that a central focus on the quality of care should be a key consideration for everyone in the system, providers, commissioners, and regulators alike. The initiatives in High Quality Care for All (June 2008) urged the NHS to put “quality at the heart of everything we do”.  However, on the basis of the evidence and Tom Kark’s closing submissions, it appears unlikely the Inquiry will be satisfied that this has been sufficiently achieved.  On this point, bear in mind that the Inquiry can have regard to matters up until the closing of evidence. 

However, not only is quality necessary to ensure patient safety, it is also increasingly becoming the distinguishing factor on which providers’ own survival is based: one of the central aims of the new regime for licensing of the sector is to ensure that competition to deliver NHS healthcare is based on quality rather than price.     

Culture

The Inquiry’s terms of reference require it to identify lessons so that “failing and potentially failing hospitals or their services are identified as soon as is practicable”.  The barriers to overcome in achieving this are many, and commentators will be able to point to countless parts of the current system where changes may lead to improvements in quality and in organisations’ ability to detect and respond to deteriorations in quality.  A theme which underpins many of these challenges is that of organisational culture and the need to establish and nurture a system in which all participants (providers, commissioners, regulators and other oversight bodies) operate a truly open and learning culture. 

Sir Bruce Keogh, in his evidence, pointed to there being four levels of input needed to address organisational failure:

• Professionalism and clinical leadership at a clinical team and individual level
• Peer surveillance
• Boards being “seen to be talking about effective care, safe care and patient experience” and
• National and regional systems which “encourage, incentivise and regulate organisations to ensure that they function as healthy organisations”.

These cultural issues underpin many of the areas which the evidence has highlighted as potential areas for improvement such as:

• Enhanced compassion within nursing
• Effective structures for patient and public involvement enabling the capture and use of patient experience
• Engagement of clinicians in, and with, management
• Encouraging the reporting of, and learning from, incidents
• The management of, and learning from, complaints and inquests
• The need for robust quality impact assessments within decision making
• Listening to staff voice
• Promotion of whistleblowing and support for whistleblowers
• Improved performance management processes

System design 

As well as recommendations which may address the culture of organisations, it remains to be seen to what extent the Inquiry will make recommendations which will address the ‘hardware’ of the system.  Again, there are numerous pointers in the evidence towards  potential changes which could be made ranging from the creation of entirely new spheres of regulation; the reallocation of responsibilities between existing agencies; the development of new, additional, standards for healthcare; improved access to, and use of, existing information on quality; and the collection and use of additional data sets.  Some of the areas which have been signalled in the evidence and closing submissions as potential areas for such re-design are:     

• The regulation of healthcare assistants
• The introduction of a duty of candour applying to organisations
•  The standards for safety and quality of care and their enforcement
• Collation, reporting and use of wider data identifying trends in patient complaints
•  A duty on providers to report ‘near misses’ to CQC.

As well as changes for providers and regulators there is likely also to be increased expectation on:

• Commissioners’ monitoring of quality - as Tom Kark QC stated in his closing submissions “commissioners must now be given the guidance, tools and data to be able to play their part in improving standards”
• Local Health Watch -  as the new champion for patients and the public; and

The Challenges for the Inquiry

The tragic events at Stafford which formed the basis against which the Inquiry carried out its primary examination of events took place between 2005 and 2009.  However, much has already changed in the healthcare system since then, and one of the tasks presented to the Inquiry is to have regard to things ‘now as well as then’.  One of the challenges for the Inquiry is how to take account of the impact those changes have had, particularly when, in some instances, they may still be bedding down.  In addition, the Inquiry needs to reflect the ongoing root and branch reform of the healthcare system in the wake of the Health and Social Care Act 2012 in determining what further changes it should recommend in its report.  

This is an incredibly difficult exercise.  The challenge is further increased by the need to ensure that any new initiatives recommended are realistic in the light of the budgetary pressures faced not only by the health sector but by the economy as a whole.   To complete the conundrum, one of the things that almost all parties agree on is the need for stability and the dangers that widescale structural re-organisation of the system can itself cause.

Despite this, much is expected of the report which is anticipated to be the most significant inquiry report into the healthcare system possibly ever, and certainly since the Bristol Royal Infirmary Inquiry, and all players in the system will need to watch developments in the Inquiry very closely.   

The Inquiry report will be of major significance to all those involved in the provision, commissioning and oversight of care.  Over the coming months, in anticipation of the report, Bevan Brittan will comment in more detail on what the themes running through the evidence to the Inquiry may mean for some of the areas which may be addressed in the Inquiry’s report:

• Employment issues (1): Staff engagement; Recruitment and staffing levels; and Standards, training and regulation
• Clinical (Quality) governance
• Governance implications for Providers – How do Boards ensure they know what is going on?
• Employment issues (2): Protecting whistleblowers; Preventing bullying and harassment; and Performance management
• Implications for commissioners.      
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