Values and boundaries in the NHS

Two weeks ago, the Royal College of Nursing at its annual conference raised concerns over low staffing levels and believed that some of the important recommendations from the Francis report such as a registration system for healthcare assistants were being ignored. This brought into focus again the failings identified by Francis, in particular the need to concentrate on a few universal truths and make changes at various levels across the health and social care system. In the third part of this series, we look at the proposals for the board and regulatory environment.

Board

‘The intelligence of an organisation is never equal to the sum of the intelligence of the people who work in it.’ Stephen Bungay, The Art of Action

As Francis points out the primary responsibility for overseeing standards of medical care lie with the board – that is ensuring front line staff provide high quality and safe care. Locally where it matters, boards not regulators hold the ring. The evidence gathered in the report pointed to a board that failed to address concerns – that did not listen to staff or patients, nor react to worrying data. They were isolated from day to day realities, with no functioning governance system and focused on the wrong things – finance, targets and self promotion. It was a board that had lost its way.

Recommendation 224 to 272 (information) relating to accurate, useful, relevant information that supports a more open and transparent system and recommendations 109 to 122 (complaints) including publication of complaints and the response on hospital websites, may have helped identify failings sooner. Francis calls for board level accountability, clear metrics on quality and investment in systems that can act as important warning signals.

We know that for data to be effective it must be meaningful, comparable, real time, open and transparent. Sir Bruce Keogh (medical director of the NHS commissioning board) has demonstrated very clearly how clinical data can improve surgical outcomes when the data is universally used and shared openly. Data should be focused and reinforced at every level so that we talk consistently about the same things because we care about them. The clinical context and the quality of care is what really motivates healthcare professionals – they want to know what they are doing and whether they are doing it well. A two way process should be adopted – ensuring on the front line that data capture is easy, meaningful and in turn is reviewed at every layer of the organisation including the board. System wide comparisons, publicly available, should be used to guide action by the board or if need be, by the regulator.

Francis states that the board’s failure, including the mismatch between resources allocated and need happened because of the system. Whilst this is true, it misses the point in that the board was the first line of defence, and if functioning properly it would have been able to ask the right questions and address these failings. Opportunities were missed.

Time, energy and resources should be devoted to increase board capability, resilience, decision-making and execution of priorities. This includes investing and developing those in executive and non-executive positions.

It is instructive that only 2 per cent of the recommendations relate to the board itself

(recommendation 37 – quality accounts, recommendation 79 – provider directors and recommendations 139 to144 – performance management and strategic oversight). In contrast, there are a host of detailed instructions relating to the processes that should be adopted by the board including complaints handling (recommendation 109 -122), healthcare standards (recommendations 19 – 59) and commissioning standards (recommendation 123 -130). This highlights the disconnect between the failings identified and the recommendations made.

Health operates in an unpredictable environment; there are often gaps between plans, actions and outcomes. These gaps are too often due to lack of knowledge, poor planning and alignment, ineffective communication and uncertainty of the effects of action. As Stephan Bungay states in the Art of Action: “Faced with a lack of knowledge, it seems logical to seek more detailed information, faced with a problem of alignment, it feels natural to issue more detailed instructions and faced with disappointment in the effects being achieved, it is quite understandable to impose more detailed controls. Unfortunately, these reactions do not solve the problem, they make it worse.”

Francis seems to be doing just that – issuing more instructions, tighter controls and gathering of more information – creating another vast set of boxes to be ticked whilst the point is missed. Any effective board should be doing most of what Francis recommends. One way or another, a bureaucratic and prescriptive response could simply make the situation worse. Whilst we should seek to improve knowledge and alignment, and simplify regulation, a different and more courageous approach is needed which focuses on doing more with the knowledge gathered, with the explicit aim of placing people and patients at its core; an approach which seeks to direct people rather than control.In so doing, boards should decide what really counts – making tough decisions on what they should be doing; getting the message across in a clear and straightforward manner to staff and patients that quality comes first, explaining their plan for service improvement, and why these intentions have been reached.

After setting a clear strategic vision, boards need to give people the space and support to take decisions for themselves within acceptable boundaries. If these boundaries are crossed then boards need to take decisive action, again reaffirming the values of the organisation – each time a line is crossed the depth of poor quality deepens. Staff and patients need to understand that the board is willing to accept nothing less than high quality and safe care.

Of course, this approach will only be successful if adopted in conjunction with changes to selection, education and training, and the cultivation of a prevailing culture that demands a meritocratic system which values independent thinking and initiative. The people in the system need to share basic values. This process is often called ‘mission command’ in the military or ‘directed opportunism’ in business. It offers a more sustainable and adaptable model for the NHS than the cyclical lurches from command and control to laissez-faire which have characterised the approach to the NHS since 1948. It needs to be encouraged, supported and become the norm across the system – Francis touches upon some of these elements but does not reinforce this message at its core. It is a missed opportunity.

Regulation

He who seeks to regulate everything by law is more likely to arouse vices than to reform them.’ Barouck Spinoz

Organisations that operate in a system need boundaries and they need to know where they stand. Regulatory standards and legal parameters are necessary.

Francis recognised that with differing regulators, focusing on different aspects of the system there is a danger of confusion and misinterpretation. Boundaries were not clear, with over-complexity hampering efforts to deliver services. Recommendation 19 is significant in that it proposes a single regulator dealing with “corporate governance, viability and compliance with patient safety and quality standards for all trusts”. This is welcome – clarity restored.

Francis proposes that the care quality commission (CQC) should take over this role with Monitor ‘regulating the health economy’. He stops short in calling for a new entity, sighting further reconfiguration as unnecessary and adding to disruption – a sentiment echoed by the CQC’s chair David Prior. Both the CQC and Monitor believe that effective regulation can be achieved through greater cooperation between the organisations, not a single or new regulator. Confusion remains.