More accountability and regulation could punish the system

In the wake of serial scandals on inadequate NHS care − from Francis, to the Care Quality Commission, the Patients’ Association and the Ombudsman − and our politicians’ desire to be seen taking strong action, the word “accountability” seems to tumble easily from many lips.

We have calls for “named accountable clinicians”, “accountability” for organisational leaders such as those swept up in the Keogh reviews, “accountability” for clinicians involved in “wilful neglect” and of course “accountability” for the current NHS chief executive.

The narrative may sound compelling but will it help anything? Can we really regulate and punish quality in the system?

‘We have calls for accountability for clinicians involved in ‘wilful neglect’ − a narrative that may sound compelling but will it help anything?’

In another public service, our schools, we are outperformed by Finland, which starts schooling later, has no comparable regime of inspection or league tables, but instead focuses on proper funding, egalitarian comprehensiveness and developmental support for teachers to enable excellence, not “naming”, “shaming” or “competition”. 

But this doesn’t suit the current politicians’ view of our public services or local government so we go for these approaches anyway. 

I don’t deny for one moment that patients’ relatives, campaigning groups or the press have a legitimate desire to see frontline staff who have abused or neglected people in their care brought to book.

Nor that organisational leaders who have fiddled data, gagged staff who raised concerns, sacrificed safe nursing numbers for cost savings, ignored coalface operational issues to focus on “strategy”, should face consequences including possible “negative registration”.

Sanctions already exist

There are, however, a range of sanctions that exist already. We have criminal, negligence and human rights law including “criminal negligence”. We have professional accreditation, registration and regulation for clinicians, regulation and inspection for organisations. Although NHS managers have resisted similar arrangements, their role is no picnic and as a medic, I wouldn’t trade places. 

Organisational leaders are held to account daily in the media, by the regulator, commissioners or Monitor. The average tenure of a trust chief executive or chief operating officer shows just how accountable people are in such challenging and complex roles.

‘The average lifespan of a trust chief exectuive shows just how accountable people are in such challenging and complex roles’

We should follow a key maxim of doing what actually works in improving patient care rather than what satisfies some kind of “in the moment” desire to sit in judgement and mete out rough justice.  I have other problems with the “A word” for a number of reasons.

Sometimes care workers get it wrong

First, the popular narrative and public conversation doesn’t differentiate between care staff getting up every morning to do a very difficult job (for instance running around emergency departments, nursing older people with dementia, immobility and incontinence, leading pressurised hospitals with ambulances stacked outside), trying to do it to the best of their abilities and sometimes getting it wrong, from those guilty of “wilful neglect”.

Good staff can be involved in poor care. It may not suit the tabloids, campaigners, online commenters or phone-in callers, but culture, leadership and organisational factors do count. Try walking a mile in the shoes of colleagues doing some of the most responsible emotionally demanding work going before slinging too much mud.

Support rather than regulation

Second, as Michael West pointed out in his excellent piece for hsj.co.uk in November, what does work in delivering good care is not heavy handed regulation, discipline and control, but leadership which values and supports employees in difficult roles, enhances their confidence and competence. High performing organisations also have high levels of staff retention, engagement and morale.

Try reading the Counting the Cost of Care report on hospital inpatients with dementia or the Royal College of Nursing’s work on safe staffing levels and you will see stories from staff who are all too aware that they can’t deliver the standards of care they would like to because of understaffing and poor leadership and support.

‘Making people “accountable” for things outside their control is unhelpful. Patients value continuity and established relationships’

Third, however superficially attractive to politicians or the tabloid commentariat, making people “accountable” for things outside their direct control is unhelpful. For instance, the new GP contract (for doctors who generally see 50 or more patients each day alongside the paperwork and admin) pushes the “named accountable clinician” model. Quite right too.

Patients value continuity, coordination and established relationships. However, making a doctor “accountable” for gaps in social care funding, community health services or nursing recruitment over which they have no direct control is unhelpful. The same applies to a sister or nurse on a ward which can’t recruit to vacancies. People are part of systems and it is unhelpful to reduce all blame to the level of individuals.

What accountability actually means

Fourth, while “command and control” or “targets and terror” may have delivered on key performance indicators such as waiting times or financial balance, we need to be clear precisely what we are holding people to account for. Perhaps some of the problems identified by Francis and others around dignity, nutrition and fundamental standards of care wouldn’t have happened if organisational leaders had their feet held to the fire for these as they were for four hours, two weeks or balance sheets.

Finally, we have to consider what the “A word” really means. We don’t exactly have people lining up for nursing roles, emergency department doctor posts or to be trust chief executives. Even in the search for an NHS leader to replace Sir David Nicholson many of the usual suspects demurred.

In my own profession of hospital medicine it takes 5-6 years of undergraduate and 10 years of postgraduate training just to become a consultant. People with that level of experience don’t grow on trees. If they make one serious “never event” error, having provided thousands of good care episodes and able to do so in the future, should they be dismissed or get performance related pay or salary cuts?

In a public service where pay for frontline staff has been frozen, pensions altered and retirement age increased (all of which I accept given austerity) and where most people’s motivation was never financial? My biggest problem with the “A word” is that if you look behind it, what the commentariat really mean is “sack them”, “strike them off” and “take their pensions away”.

I don’t deny that this might be appropriate for the most heinous offenders but by and large it’s an unhelpful narrative. To quote the American journalist H.L. Mencken: “For every complex human problem, there is a solution which is simple, obvious and wrong.”

David Oliver is visiting professor of medicine for older people at City University, London, and a commissioner on HSJ’’s Commission on the Hospital Care of the Frail Elderly