Mid Staffordshire Hospital: Making the Right Changes
Professors David Buchanan & Mike Bourne
Steve Macaulay
The scandal of lack of care and high death rates over a number of years has
raised important questions not just about Mid Staffs hospital but about
society and about the NHS. We have got two experts in the studio to look at
some important managerial issues. One is culture and the other is
performance indicators and measures and targets. The two people are David
Buchanan and Mike Bourne. David let’s start with you. Culture, what’s gone
wrong there? It clearly has gone wrong, very badly and what do we do about
it?
David Buchanan
First of all let me say Steve that really was an appalling set of outcomes at
Mid Staffs and as you have just said one of the key recommendations from
the Francis inquiry which has been picked up by the press has been about
changing the culture of the NHS. The NHS must have a more patient centred
culture than it has at the moment. On research I wouldn’t suggest that that’s
nonsense, let me explain why. As you know we have just finished a major
three year study of the changing role of middle managers in acute care and
that group of middle managers includes not just full time professional
managers but also ward managers, ward sisters, modern matrons, senior
nurses who have management roles, we asked them what their main
motives were, what drove them, where did they get their rewards in those
roles. The five main motives were, making a difference for patients,
delivering innovation and change, doing a good job, feeling valued and
developing others. What I am trying to say Steve is that patient centred
culture is already there, it is actually deeply embedded. The NHS has not
mysteriously managed to recruit one point three million Harold Shipmans
and Beverly Allitts over the last five year, that hasn’t happened. I think we
have to look at Phillip Zimbardo’s analogy an American psychologist who
talks about bad behaviour but he explains bad behaviour in terms of bad
apples, bad barrels and bad barrel makers and a close reading of the Francis
report suggests that we need to be looking at the barrel makers not just at
the bad apples and bad barrels.
Steve Macaulay
So tell me some more about that, because the average person would just
say, this doesn’t seem right really, do we look at just that?
David Buchanan
If we go back to the motives that take staff into the health service, those
motives are stifled systematically by a number of factors, the first of those
and probably the most important is that the NHS has a top-down
prescriptive autocratic leadership style, that comes from the top, it comes
from politicians, it comes from Department of Health national figures and
that style is automatically cascaded down into the system. So the first
reason for that culture being stifled is simply management style, leadership
style, it’s autocratic, it’s not supportive. Second feature is we have within
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Mid Staffordshire Hospital: Making the Right Changes
the NHS a highly prescriptive and very punitive and complex regulatory
regime, do as you are told, basically is what that says. We also have constant
tinkering with structures and with the details of the system with that
regulatory regime, the coalition government was elected on a promise not
to drive any further top-down reorganisations of the NHS, that’s the first
thing they did and those changes are still going through so those structures
are constantly changing and people have to learn how to work with new
structures, new relationships, new people all the time, and I would also have
to add that the government, this is, we have an austerity programme, but
the cost improvement programmes that are imposed on acute care in
particular, are extremely burdensome. Only four per cent a year recurring
finance cuts, but if you are a moderate size hospital with a four hundred
million pound budget, four per cent is sixty million pounds and sixty per cent
to seventy per cent of your annual spend goes on payroll, healthcare and
quality has to suffer if that continues.
Steve Macaulay
That feels like a very thorough analysis. Having said that, it all went wrong
spectacularly at Mid Staffs, where do we go from here?
David Buchanan
I think the prescription is probably very simple to state, but one would have
to recognise perhaps more difficult and complex to implement. I think going
back to the reasons why that culture is stifled. I think change has to start at
the top and it has to start with leadership style, start with management style
and start with some of the kinds of commentary that politicians repeatedly
make about the nature of the staff and the people who manage the health
service, that has to change. The leadership style has to be more supportive,
more listening. I think the regulatory regime would benefit from being
simplified and streamlined perhaps including a shift away from the
prescription and inspection regime that the Care Quality Commission
operates to what’s called a “safety case approach” which puts the
responsibility on providers not on the inspectorate agency. I think it would
also be useful and would cost nothing to give the NHS a period of relative
stability, breathing space that allows some of the innovation that is required
to happen and take root and unpopular remark at this stage in the economic
cycle but I think it would be useful to take another look at the pace and scale
of funding cuts that the NHS has been asked to make.
Steve Macaulay
Now let’s have a look Mike at your perception, you’ve got a lot of experience
of performance indicators, performance measures, not just in the public
sector but in the private sector too. What are your perceptions about what’s
gone wrong here and again where do we go from here?
Mike Bourne
Some classical mistakes made at Mid Staffs. One of the key ones is how do
we manage performance. They focussed almost exclusively on the financial
measures and we have known for thirty years within the business
community that that’s a disaster, you have got to look at measures in the
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Mid Staffordshire Hospital: Making the Right Changes
round and that focus on financials at the expense of everything else went
wrong. The second and really important point is about feedback.
Measurement isn’t just there for forcing people what to do, it’s about
feedback and systematically in Mid Staffs they forgot about the feedback,
especially as the soft measures the measures about perceptions of care
were not taken into account by the Board, that was a real issue for Mid
Staffs because they then just ignored them and didn’t take any point. Finally
I think the regulation is a real issue. If you have people coming into regulate
you day in and day out with prescriptions and actions plans day in and day
out when do you actually treat the patients. I think they should take a knife
to the regulation regime, they need to cut it down, probably two regulators
overall and the rest has got to be down to local people. If you have
professional staff, you’ve got to expect them to perform professionally and
you don’t regulate them to death.
Steve Macaulay
Gentlemen any final thoughts?
David Buchanan
I would have to agree with everything that Mike said there. We are in
danger I think possibly of abandoning the concept of targets and
performance measures altogether and I think that would be a mistake, I
think the health service, many people in the health service recognise that a
lot of the benefits and waiting times in general in accident and emergency
units in particular have benefitted through the imposition of targets but
what we have had and what Mike describes is what is colloquially known as
a targets and terror regime, we can have the targets without the terror.
Steve Macaulay
And some final thoughts from you Mike.
Mike Bourne
There is nothing wrong with measures and targets per se because they
communicate to the organisation what they are trying to achieve, but you
have got to use them in the right way. If you use them to learn and improve
that is what they are there for, if you use them to terrorise people, people
get terrorised and act accordingly and that’s what we have got to do to get
the NHS back on track.
Steve Macaulay
Gentlemen, both of you, thank you very much.
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