Mid Staffs must be the barometer of change

The first limb of the government’s initial response to the Francis report focused on “preventing problems”. Meeting this objective entails bringing about a cultural change at all levels of the NHS, but is this achievable?

‘The key principles of the revised NHS constitution have not been written with the robustness of language one would have expected’

One of the criticisms of Mid Staffordshire Foundation Trust was that the focus was on the wrong things − “hitting the target but missing the point”. The government accepts Robert Francis QC’s view that a cultural change is required and has sought to outline a series of measures to “revitalise the culture of the NHS around a consistent focus on the needs of the patients it serves”, never losing sight of the core values of compassion and care.

While acknowledging that every team will have its own distinct culture, the government agrees with Mr Francis’ conclusion that the common values and cultural attributes that should be fostered across the NHS should be set out in the NHS constitution.

Constitutional change

In March 2013 a revised constitution was published. This was accompanied by a revised handbook. That is not the end of the matter, however, and there is to be yet more consultation this year to respond more fully to the Francis report’s recommendations. At present, the principles are as follows:

1. The NHS provides a comprehensive service, available to all.
2. Access to NHS services is based on clinical need, not on an individual’s ability to pay.
3. The NHS aspires to the highest standards of excellence and professionalism.
4. The NHS aspires to put patients at the heart of everything it does.
5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.
6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
7. The NHS is accountable to the public, communities and patients that it serves.

Even at the present juncture, many have argued the government has missed an opportunity. While the constitution has no doubt been strengthened, the seven key principles have not been written with the robustness of language one would have expected. After all that has been said by Mr Francis, the fourth principle is unfortunately phrased in the tenor of an aspiration.

Within the core values, it is stated that “patients come first in everything we do” so why the principle uses the aspirational and less robust language is something of a mystery. However, to stem the criticisms that followed the redrafted constitution, health secretary Jeremy Hunt has confirmed there will be another round of consultations later this year on changing the constitution.

Be that as it may, the current version is much enhanced, and the spirit and message is clear − put patients first, and create and maintain the right culture to deliver high quality care that is responsive to patients’ needs and preferences.

However, it takes more than a revamped Constitution to bring about a cultural shift in attitude.

Culture shock

The King’s Fund identifies a number of factors that characterise a good culture of care. These include:

• developing a clear vision for quality;
• supporting staff to deliver the best care;
• boards developing the right culture;
• being responsive to patients’ needs and preferences;
• having an open and just environment;
• adopting the right leadership styles;
• thinking and acting for the long term.

In another article, Implementing culture change in health care: theory and practice, Scott et al note the following barriers that block purposeful change:

• Lack of ownership – unless a critical mass of employees “buy into” a culture change programme, such initiatives are likely to fail.
• Complexity – successful strategies require realistic timeframes to implement the types of complex and multi-level changes required.
• External influence – the influence of outside interests may sometimes work against efforts towards internal reform.
• Lack of appropriate leadership – appropriate leadership not only modifies familiar behaviour, but redefines interpretations and experiences of health care.
• Cultural diversity – a key challenge to culture change programmes is to consider the impact of change on specific groups (doctors, nurses and other health professionals) and to design appropriate policies to accommodate this.
• Dysfunctional consequences – cultural change policies can bring a range of unintended consequences. Increased focus on performance targets has resulted in a concentration on areas that are measured to the detriment of others, concentration on short term issues, and the misrepresentation of data.

Central to the government’s desire to bring about a cultural change is the creation of the chief inspector of hospitals role. They will “shine a powerful light on the culture of hospitals, driving change through national ratings, which put the experience of patients at their heart”. The chief inspector will provide oversight to the Care Quality Commission’s inspections, assessments and ratings of providers and will communicate findings to the public.

In reality, the evidence will come from the team of highly skilled and trained inspectors on the ground, supported by data about complaints, whistleblowing, patient experience and staff experience. These inspectors must not only be given the resources to undertake their functions, but must also truly understand the DNA of the NHS.

This is vital if they are to engage in a shared language with NHS managers and report back in a manner that shows an understanding of findings and clear objectives for improvements where appropriate.

New landscape

The new commissioning landscape is also expected to safeguard patient care and respond to many of the concerns highlighted by Robert Francis. Clinically led commissioning, together with the new role of health and wellbeing boards should provide a platform for partnership working, thereby improving outcomes for the whole population.

This is undoubtedly a significant cultural shift in the way the health system is managed, but there is a risk of inconsistencies occurring across the national piste. A clinical commissioning group that works well with its other stakeholders (including patient groups) will drive through these cultural changes, while others may − again for deep-seated cultural reasons − not manage to bring about the required change.

In the studies mentioned above, the importance of buy-in from staff was highlighted; this has been recognised by the government. The government’s response makes it clear that board behaviour and leadership − including how they engage those they lead to ensure they are not unsupported − will be an important focus for the chief inspector of hospitals.

‘Mid Staffordshire must cease to be an example of failing, but should be the barometer that brought about change’

NHS providers are promised a working environment that is “unconstrained by a culture of bureaucratic compliance with national regulations” and in which “paperwork, box ticking and duplicatory regulation and information burdens” will be reduced by at least one third. The NHS Confederation is undertaking a review of bureaucratic burdens on NHS providers and will report in September.

Zero harm is an aspiration embedded in a culture of safety. At the end of July we expect to receive the report from the national advisory group on the safety of patients in England led by Don Berwick into a whole system approach to make zero harm a reality in the NHS. The key stakeholders will then consider how to take this forward. In addition, NHS England will develop and deliver a revised and responsive national reporting and learning system to provide a single place for the NHS, clinicians, patients and the public to report patient safety incidents and receive advice.

Collectively, all of the above will drive the government’s agenda on openness and transparency. The scale of the shift in culture required to turn these aspirations into reality and to prevent another Mid Staffordshire is immense. It depends not on the government’s response per se, but also on the willingness of each provider, commissioner, regulator and user to believe that change is possible.

The picture is not completely bleak − there are some NHS bodies that already embrace the tenets of change, although others do still have some way to go. Mid Staffordshire must cease to be an example of failing, but should be the barometer that brought about change.

Dawn Brathwaite is partner at Mills and Reeve