Stronger and more accountable Foundation Trusts needed to avoid “Staffordshire 2”
Posted: 27 February, 2010 by Andrew Craig
At least 400 died needlessly
“These patients were not simply numbers: they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives.”
The enquiry was published this week on deaths at the Stafford Hospital part of the Mid Staffordshire NHS Foundation Trust between 2005 and 2009. It should be required reading – all 455 pages of it - for commissioners and Trust board members everywhere. What happened in Staffordshire could happen elsewhere unless governance and clinical behaviour are drastically improved.
Don’t just read the recommendations or you will miss the outrage you should feel at the recurring catalogue of systemic clinical, governance and above all individual failings (nurses but also doctors and managers) that resulted in the untimely deaths of some 400 people (maybe up to 1200 according to some accounts). If a train crash killed 400 people, there would be an immediate public enquiry and Ministers would be front and centre. But that’s not what happened here.
No openness: no challenge: no change
The Francis enquiry report is not strong enough on improving Foundation Trust governance. It largely ignores the role of the Trust’s owners – the Members of the Foundation Trust and their elected Governors. A Foundation Trust is after all defined in law as a “public benefit corporation” – a species of social enterprise - but what that means in practice has been deliberately fudged by Ministers and Monitor since FTs were first created. Now we can see what that sort of “governance neglect” can lead to. Francis could have made a big stride forward to rectify that, but instead it made a rather bland recommendation to empower members and governors. Much, much more needs to be done about ensuring there are stronger public and service user Governors and – crucially – about empowering staff governors elected from the Trust’s own workforce.
Then there is the role of the Local Involvement Network (LINk). Why was there not a functioning LINk locally? Why were there no unannounced visits to these wards under enter and view powers and reports made to the local authority and the PCT about obvious care shortcomings? I cannot image a Community Health Council (CHC) pre their abolition in 2003 failing to respond vocally to the first reports of failing standards. This is a measure of what we have lost in local accountability.
Closed enquiry
In Staffordshire theenquiry led by Robert Francis QC was closed and so most members of the public and the media outside the region were not even aware of until it reported this week. To its credit the Francis team produced a good report, concluding that patients were routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes and which lost sight of its fundamental responsibility to provide safe care in a headlong pursuit for Foundation Trust status which it achieved in January 2008.
But however good its recommendations, this process isn’t the same as a robust enquiry held in the public and media eye and it falls far short of assigning responsibility for these failings to individuals. Only individuals can be held to account for this magnitude of institutional failure. Think casino investment banks. The Trust as a corporate body and its culture are only the reflection of the sum of the behaviours and attitudes of the people who comprise it - the clinical staff, managers and board members in particular. Some of them did try to raise the alarm, but most did not. Some were cowed into silence, but it seems that most chose to look the other way. Or maybe they just could not believe it was happening to them.
Where were the nurses?
Most worrying of all is the question “where was the voice of professional nursing as the patients’ champion?” The Trust’s diverse nursing team are the most numerous group of employees and always will be. They are everywhere and they see everything. Had nurses taken a united stand and made their collective voice heard, the care failings of the Trust would have come to light much earlier. Where were the letters to MPs that the hundreds of nurses working in this hospital should have written? Where were the local nursing clinical leaders? Where were the nursing trade unions and professional bodies?
Does the buck stop nowhere?
If people knew and did nothing, that must be culpable if not criminal. If some senior people at the Trust are not personally held to account for this, then the message is “the buck stops nowhere” and accountability is reduced to a cipher. Relatives are demanding responsibility at this level and so too should the public because this outrage took place at a time when the NHS has never been more regulated and this Foundation Trust was – on paper – rated a good, and safe, provider of services. But no one challenged the failures.
Governance matters
The enquiry recommendations could have clarified that the governance of the Foundation Trust must be rooted in the membership community and its elected representatives whose role is to hold the Board to account and who must be supported to carry out that role. This seems to be what the Secretary of State Andy Burnham is now talking about in his reported views about strengthening the Governors of FTs . Will he translate these words into action?
This Foundation Trust’s board meetings were held in private. That was wrong and Mr Burnham has now declared in a parliamentary answer that FT Boards must meet in public and Governors must have access to all Board papers. There is still some wiggle room in that which needs clarifying. It is welcome, but in itself it will not solve the problem of a culture opposed to openness and challenge.
It is an indictment that without the persistence of “Cure the NHS” - a local group of patients and relatives who knew that things were going wrong within the hospital, who raised complaints and whose members kept shouting despite efforts to silence them – the magnitude of this scandal would never have come to light. Their contribution is praiseworthy, but they should not have had to make it alone. The Foundation Trust is after all “owned” by its Members who elect a Council of Governors to hold the directors of the business (the Board) to account for delivering safe, effective services and fulfilling their strategic plan.
Stronger Governors needed now
Should FT Governors therefore have a role in the complaints process? That is one option raised by Francis, along with the possibility of the Governors electing their own chair instead of sharing a Chair with the Board as currently. Both suggestions have merit and need serious consideration. Governors could be effective scrutineers of the complaints process (which could do with improving its performance in many Trusts), but should not as individuals get directly involved in complaints handling. And Governors deserve their own, independent chair. Having the same person chair the Board and the Governors invites conflicts of interest as was obviously the case in Staffordshire.
FTs at a crossroads
The Mid Staffordshire scandal shows Foundation Trusts at a crossroads. We must learn from this and quickly because all other NHS Trusts are headed for Foundation status or else franchising from an existing FT. These “community benefit corporations” must be made to behave for the benefit of the community and be accountable to its representatives. They must be directed by Government down the road of greater local accountable to their Membership communities through stronger, more effective Governors – public and staff. If this does not happen, then it is just a question of waiting for “Staffordshire 2” to happen.
Tweet
Nothing matters but an answer to the question – where were the nurses? They are front-line hands-on and ubiquitous. They MUST have known what was going on. They could not have been blind to events. Why they did not speak out is the only question – the answer to which will giude us in trying to make sure this ‘plane-crash’ of deaths does not happen again.
Where were the Nurses? For sure they weren’t in control-risk-self-assessment (crsa)workshops being facilitated to identify, analyse and report (anonymously in confidence) key issues obstructing the achievement of excellent patient experience and safety.
It would be good to hear from NHS organisations who have kept faith in crsa and can report succesful outcomes from their investment.
Lead Consultant for Assurance, Governance and Risk Management, Parkhill
Member, national crsa forum
Leena Sudano working as a healthcare complaints professional in an Ombudsman role in South Australia sends us this comment:
Thanks again for another great e-bulletin.
The issue of weak governance leading to preventable harm is perennial in health care, as is the question you pose about nurses.
You may be interested in one contribution to trying to arm nurses to speak up about what they see & hear. I have used it to address the issue of speaking up when the action/inaction of colleagues puts patient safety at risk & dealing better with complaints at point of service – it is largely the same skills set for dealing with high stakes, high emotions, varying strong opinions.
The original information is at http://www.silencekills.com/.
We have noticed an improvement in complaints handling in those services where a senior nurse has participated in Safer Conversations training.
We have also noticed contacts from nurses who have participated in Safer Conversations training, who have concerns about unsafe practices, seeking advice about speaking up (not strictly our core business but we deal with it in the public interest by coaching in the background &, as a last resort, accepting a complaint from them (we do not reveal their identity)
The culture of concealment in health care services has a long history & protects very powerful interests, this is just one small step
The lack of a staff or board response to the problem presupposes that the problem was actually evident to the staff or board. It seems likely that the problems at Mid-Staffordshire appeared fairly run-of-the-mill to most of those involved at the time; there is a great deal of avoidable harm & death in hospitals normally, even when they’re not trying to save money etc. What’s disturbing is that Mid-Staffordshire was only slightly worse (if it really was), not that it was some awful travesty. Look into the detail of any hospital you like and you’ll find much the same sad picture. “Staffordshire 2″ has already happened: Basildon & Thurrock and Tameside have been recently “outed” and I’m sure that’s just the start. Perhaps this FT experiment is not redeemable.
I am afraid the FT movement is doomed to failure.
First there is not the management talent to be allowed and left alone to run them. In most instances FTs are bigger than most companies on the FT100 – they are not run they are administrated and there is not a national talent pool of really good people to run them. There are exceptions and we are mesmerised by the exceptions, and their progress, into believing ‘we can do it too’. We can’t.
Second, FTs only work if ‘we are all FTs’. For the reasons I have put before you we will dilute the brand and the mediocre will set the bar.
In the absence of realistic monitoring/regulation; CQC look for statistical exceptions, turn-up and count the dead, and (as far as I can see) Monitor count each other, there is no way to guarantee the quality or solvency. 400 Trusts is just too many. We cannot trust the quality. 400 people dead at Stafford and everyone runs for cover. If Virgin killed 400 in an airplane crash there would be a public enquiry. We don’t ask because we know the answers; pressures on staff killed 400 people. The pressures are politically driven – the quest for policy vindication. ‘It was our idea and it works’………….
They are unable to use their freedoms (for local pay and conditions, for example) as organisations like the RCN and Unison would make life too difficult for the politicians and because there is not enough money in the system to make it work. I was the only Trust to have 80% of staff on local pay and conditions in the mid-90’s. After I left they were forced back into national pay bargaining. Today, manipulation of the tariff (by Ministers) would put too many uncertainties into the mix. You can’t risk going it alone. Today’s FTs are plastic FTs, not the real thing. No real public buy-in, not separate from the NHS and all that – valid criticisms.
Third, FTs are publicly funded by money allocated from taxation. Ministers are responsible and no, they won’t let the thing go. They can’t. If a constituent turns up in a surgery with a valid complaint about an FT, the MP will have to act in the same way as if it were a Trust.
If there is to be step change it is in commissioning. WCC is in a bureaucratic muddle. I spoke with a commissioner yesterday who has spent 3 months trying to set up a community therapy contract. No one knows what they want or how much it all costs. The value is £120,000 – not worth bothering with. Doing more of the same is a very sensible compromise in the circumstances.
However, it is ‘buying’ that makes M&S and Tesco and Morrison’s what they are. Tesco gets into to trouble for screwing the farmers, but we get cheap milk and great lamb-chops. If Commissioners screwed hospitals would we get better services – yes. But, the problem is Tesco can go to 500 farmers both here and in Europe. Commissioners (by and large) are stuck with the hospital up the road – even if we all know it’s a basket case. Shutting it is not an option.
There are no levers that really work. The answer? Sell the NHS on a regional basis to insurers? Maybe? Have a look at how Israel works. Three insurers, you must belong to one of them, they can’t dump you if you are old or costly, you can change ‘supplier’ twice a year and if you can’t pay the government will. And, they have to offer a full menu.
There is no public appetite for that. So, soldier-on in the pursuit of efficiency? Policy documents are fun but only for the unemployed to write and the under occupied to read!
Roy Lilley
http://www.roylilley.co.uk