How to fix the NHS? Let’s start at the very beginning..

How do you fix the NHS? A $64,000 question – or more accurately a £100 billion problem. Out of bad comes good – we hope – and the Mid Staffs scandal must surely be the turning point for change. The avoidable deaths of over 1,000 patients and the maltreatment of many, many more has got to be the trigger for improved care, accountable management driving ownership and responsibility among every employee of any care facility. We are all hoping that this must be where the line is drawn – yet there are still examples of poor, even bad, care happening now, today, this moment, in hospitals and care homes throughout the UK.

How do we bring about change? The NHS has often been compared to the Titanic, both in size and mortality, but the major issue is neither, it’s the speed at which it can change direction that’s the problem.

With a nod to change management experts worldwide – where should the NHS start to bring about this crucial evolution to balance technical expertise, cutting edge medical treatment and good old fashioned basic care?

Adopt a clear vision and strategy:

In theory – the Health and Social Care Bill should provide both. Andrew Lansley, the former Health Secretary may have had a clear vision in his mind of how his perfect NHS would look but he failed to translate this into a tangible and workable strategy. It is now down to the new Health Secretary, the Department of Health, Clinical Commissioning Groups, Hospital Executives and Monitor and other organisations too many to mention, to make some sort of sense of a Bill we are now stuck with. Clear goals (and forgive me, but maybe the odd target) are called for.

Start at the top:

No-one can now argue that the culture of the NHS needs serious attention. How do you change culture? No apologies for repeating my favourite mantra – you start at the top. David Nicholson must go. What a shame he hasn’t had the decency to fall on his sword. You have had plenty of time to make things better Sir David, and the 1 million plus NHS employees need to understand that performance management is a vital element of a successful organisation. Nicholson has not achieved what he is paid to do so he must go. Forget scapegoats – if someone doesn’t perform well they either need additional training and guidance or they move on. This shouldn’t just apply to the Chief Executive of the NHS – among the multi-layered beaurocracy, especially in hospital trusts and PCT’s – there are underperforming senior personnel who have been flying under the radar for far too long. The NHS desperately needs good leaders – not just managers – leaders.

Involve every layer and create ownership:

This is where responsibility and accountability comes in. Every act of negligence, cruelty or just plain incompetence is down the perpetrator. Every individual involved in the delivery of care, whether as a porter, surgeon, nurse, healthcare assistant or even ward clerk, makes a decision to be exceptional or ordinary, kind or cruel, diligent or lazy, competent or incompetent. I am not so naïve to believe that it is so simple. Toxic culture can turn good people bad. A caring person can have an off day and let their standards slip. But they must realise that blaming the boss, colleagues, economic environment, pressure or even ‘time of the month’ is absolutely no excuse for lack of care. Badges noting name and job title for ALL patient facing staff is a good place to start.

Communication:

A care facility must make it absolutely plain to patients and staff which standards are acceptable and how these standards will be measured. As changes start, employee engagement is essential and it is only through ‘stakeholder buy-in’ that real change can take place.

Reward good behaviour and punish bad behaviour:

Effective change management is like good parenting.

Provide support, mentoring and guidance for all staff:

Effective management is like good parenting! And leaders – don’t forget that managers need support, mentoring and guidance too. This is appropriate at ward level and board level.

Create measurable goals:

What does good care look like? The 6 c’s created by the Royal College of Nursing (Care, Compassion, Commitment, Courage, Communication and Competence.) are all very well but what do they actually mean? Goals should follow the SMART principle - Specific, Measurable, Attainable, Realistic and Timely. No more sound bites but tangible monitoring. Patient and carer questionnaires, regular performance appraisals, and ongoing training at the very least.

Empower all stakeholders:

'Nothing about me without me’ was one of Lansley’s favourite phrases. Yes – it is jargon but the principle behind it is sound. Don’t just say we are giving patients and carers a voice. Make it happen – at every stage of the care pathway. One of the most shocking elements of the Mid Staffs debacle is the way that Julie Bailey, whose mother, Bella died in the hospital, and many other relatives of members of Cure The NHS were treated. Unforgivable. ‘Whistleblowing’ doesn’t just apply to staff, it should be a given for all. But it should also be a last resort. We cannot rely on whistleblowing to fix the NHS, but it must be an acceptable route for all those with a conscience to follow. I hope that this will be one of the lasting legacies of the Francis report following his enquiry into this hospital’s maltreatment of so many patients.  I long for the day when whistleblowing is rare – not because it’s discouraged, but because it’s no longer need. What a Utopian vision!

And finally..

Make sure that the change is sustainable:

No quick fixes – quick wins yes, but supported by long term, realistic plans. The majority of care in the NHS is good, sometimes exceptionally so. But sadly, bad care is more common than it should be and even worse, in some areas, accepted as a tolerated norm. The process of change needs to ensure that we look on the first decade of the 21^st century as the bad old days of state managed care, never to be repeated.

David Nicholson should step down as Chief Executive of the NHS

Robert Francis stated in his report following the Mid Staffs care scandal that ‘what has been found to be wrong here cannot be cured by finding scapegoats’.

Francis may have a point, but that doesn’t mean that those who are actually to blame for individual acts of negligence and cruelty should not be brought to book and if appropriate, face criminal prosecution. What about the cultural breakdown which has created ghettos that are literally unfit for purpose within our hospitals and care facilities? One definition of scapegoat is ‘one that is made to bear the blame of others’. Yes, the creation of scapegoats would be a bad move, but fixing the NHS is not just a blame game, it’s about shouldering responsibility and accepting individual ownership by staff at all levels. How can it be possible that so many atrocities have taken place in facilities with an abundance of leaders and managers?

What creates a positive, productive and benevolent culture in any workplace? Good leaders. Ultimately who has responsibility for the culture of an organisation? The man (or woman) at the top.

One could ignore the unfortunate fact that the Chief Executive of the NHS, Sir David Nicholson was interim chief executive at the health authority responsible for Mid Staffs Hospital at the time that the high death rate at the hospital was beginning to draw attention. But what cannot be ignored is his tenure at the top job in the NHS since 2006. Nicholson has been ‘in charge’ for over six years. As courage grows within clinical and support staff, more and more shocking and frightening cases of poor management and substandard care are coming to light. On your watch Sir David. On your watch.

Sometimes the best person to fix a major problem within an organisation can be the Chief Executive but more often they are not, especially if they’ve been at the helm as the situation developed and worsened.

I started project management within the NHS four years ago and was surprised to note that despite my dealings with senior clinicians, ward staff and hospital managers, Nicholson’s name was never, never mentioned. Andrew Lansley, the Health Secretary at the time was often pilloried, discussed and on a rare occasion, even supported, but Nicholson was just a non-personality, absent both physically and emotionally it would appear.

Let’s give the Chief Executive the benefit of the doubt and assume that his low profile meant that he was busy working behind the scenes rather than playing an astute political game to protect his position. Anyone can be forgiven a little self-protectionism. Up to a point.

The tipping point for me was watching Nicholson’s interview on the 6^th February following the Francis report. He came across as a cold fish, and he said ‘….At the time I apologised and in a sense I apologise again to the people of Stafford for what happened, but apologies are not enough we need action, we need to make things happen and right since 2009 we have doing things in the NHS, we’ve been tackling healthcare associated infection, we’ve been tackling stroke services…. Heart disease .…we’ve literally saved tens of thousands of lives and the NHS is committed to that….’ What an opportunity missed – this came across as a political speech rather than a genuine concern for the patients lost and sympathy for their devastated loved ones. ‘..in a sense I apologise again’ – cold comfort for the bereaved relatives. At the time I bravely (or maybe foolishly – I really want to continue working with the NHS) tweeted.. ‘Just heard the re-run of the Nicholson interview. What an incredible lack of empathy and humanity. Shocking.’ Needless to say, this was much re-tweeted.

I have no doubt that Sir David does care, in his own personal way, but is he the right person to lead from the front and introduce a new era of patient first? Charismatic? Empathetic? Accountable? Inspirational?

I think not.

Should the Francis report recommendations replace the Health and Social Care Bill?

Robert Francis QC strikes me as (in the words of my grandmother) a sensible sort of chap. This may seem a frivolous start to any commentary on the Mid Staffs report, especially considering the horrors suffered by not tens, but hundreds of patients. But it is good sense that is needed to fix not only Mid Staffs, but the NHS in general.

This highly significant landmark in the future development of the NHS has been sublimely covered by the Health Services Journal and I am still absorbing the key points. I particularly like the infographic ‘how the report will affect the key players’.

http://www.hsj.co.uk/infographic-how-the-francis-report-affects-the-key-players/5054618.article?blocktitle=Most-popular&contentID=-1

 

But for simplicity, I am including some top recommendations highlighted by the BBC website:

·        The merger of the regulation of care into one body - two are currently involved

·        Senior managers to be given a code of conduct and the ability to disqualify them if they are not fit to hold such positions

·        Hiding information about poor care to become a criminal offence as would failing to adhere to basic standards that lead to death or serious harm

·        A statutory obligation on doctors and nurses for a duty of candour so they are open with patients about mistakes

·        An increased focus on compassion in the recruitment, training and education of nurses, including an aptitude test for new recruits and regular checks of competence as is being rolled out for doctors

I haven’t assimilated all the information in this report yet but share the view of so many – how could this have happened and why hasn’t anyone paid for the ‘appalling suffering and abuse’ with their jobs?

The Francis report addresses ‘patient abuse and cruelty’, ‘corporate self-interest’, and ‘administration remote from the service at the front line’ He goes on to mention a ‘reluctance of those with the power to do so, to intervene urgently to protect patient’s interest’ and the ‘institutional culture’ is quoted as culpable.

I agree with Francis when he says that what is wrong cannot be cured by finding scapegoats. However in my opinion, that shouldn’t mean that those who must shoulder some blame should stay in post. From the ward to the boardroom – the key players and perpetrators should face the consequences of their action or inaction.

Cruelty and abuse was undertaken by human beings with free will. No-one made a nurse ignore a patient’s cry for help. The lack of conscience in a senior manager viewing their own professional ambitions and putting patients’ needs out of mind was a personal choice. Those with the power to intervene chose to ignore damning statistics and the pleas of distressed relatives.

In order to change culture, the top needs to lead by example. Anyone with some authority needs to think patient. Commissioners, chief executives, ward sisters and clinical leads must demonstrate that they care – in every sense of the word. They care about doing a good job, they care for the people whom they treat, they care for their colleagues and they care about outcomes. I absolutely agree with Francis when he recommends improvement in recruitment, training and education of clinical teams. I also agree that there should be one regulatory body monitoring care and standards.

Let us not forget that five other hospitals with above average mortality rates are facing investigations so Mid Staffs is not the only bête noire. I am a feisty, educated woman who understands how to play the system to get the best care, but even I have witnessed, and experienced at first hand a nurse being mean and a doctor ignoring my wishes.  So what chance would a vulnerable elderly patient stand?

The complex top down reorganisation as prescribed by the current NHS reforms will do nothing to address the care crisis faced by the NHS, but the recommendations by Robert Francis might just do it. Accountability, responsibility and honesty should be the NHS mantra.

What a pity that so much effort and resource has been applied to implementing Lansley’s Bill when the time and money could have been better spent addressing the real care crisis in our much loved, but nearly broken, state funded system. It just makes sense really - doesn't it?

Is Europe good for the NHS or is the NHS good for Europe?

I took part in a fascinating event yesterday, a Balance of Competencies Review meeting. In true tradition of government speak – as the invitation popped into my inbox my first question was ‘what?’  But actually the aim of the review is pretty straightforward – to gather evidence to submit to a health report required by the Foreign Secretary with the following brief: To undertake an audit of what the EU does and its impact on the UK – what this means for UK national interest.

I was immediately impressed with the diversity and calibre of the audience – representatives from the Royal colleges, NHS departments running overseas visitor services, the pharmaceutical industry, charities, the food industry and independent commentators and service providers. We had limited time available to brainstorm the positives and negatives of EU membership from the perspective of public health, the NHS, and medical devices and medicines.

 

I joined the NHS workshop and although I suspect the organisers didn’t learn anything new from the gathered ‘experts’ it was interesting to note the polarity of views. Despite a request to keep things ‘high level’ the group understandably kept slipping towards minutiae and local specifics. We discussed the report, ‘Patient choice beyond borders’ issued by the NHS European office in May 2011. The EU directive confirming the right of patients to receive healthcare in another EU member state will become law in October 2013. In simple terms, patients can travel to any member state to receive care that would be available in their home country and the cost (excluding travel and accommodation) must be reimbursed by the home country. The treatment tariff from the home country will apply. There have already been some test cases where the European Court of Justice decided in favour of the claimants, and ruled that a PCT should reimburse UK patients for their elective overseas treatment. Pre-authorisation is desirable but not essential. There is already a steady flow or European patients attending the NHS for treatment. But is this free movement of patients and staff good or bad for the NHS and the UK in general? Cue a heated discussion….

It was agreed that most of the negatives and pitfalls of accepting European patients into the NHS are not due to EU law, but down to the fact that our healthcare is a ‘residency based system’ so if someone is ‘residing’ in the UK – they are likely to be treated. It is the way we police this treatment of ‘visitors’ in hospitals that leads to a significant number of patients receiving care for which the UK is not reimbursed. But is this the EU’s fault? No it’s not. The point was made that UK citizens travelling to Europe for treatment remove themselves from the duty of the care of the NHS for that treatment so they are at the mercy of their chosen facility. This highlights the need for some sort of central information service to report on standards and clinical governance – a bit like Tripadvisor for health!

The pluses of an open European market for health are exciting and manifold and as the discussion continued, I found myself becoming increasingly Europhile! Shared data, research, the creation of world renowned centres of excellence are all tangible opportunities to bring much needed income into the NHS. The way that Great Ormond Street Hospital has become a global brand is a good example of how we could promote specialist services throughout Europe. Another sensitive issue is cross border employment. The risk of losing doctors and nurses to overseas competitors is offset by a significant number of European clinicians choosing to work in the UK. Language is a major hurdle to be overcome, but again this is down to local management – if an EU migrant worker does not have sufficient language skills to do their job properly then a hospital is under no obligation to employ them.

This blog only scratches the surface of what was discussed at the review and the scope of evidence to be collected is mind blowing. But I was left with a new insight on the European Union and the potential it can offer. So many of our negatives against this free market are down to local interpretation, the generous way the NHS is set up,  poor reimbursement collection systems and dare I say, narrow minds.

What about the elephant in the room? David Cameron’s referendum that could potentially exclude us from the EU? It wasn’t mentioned..