Did the government ignore criticisms of the NHSin the run up to the Mid Staffs scandal?BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f652 (Published 05 February 2013) Cite this as: BMJ 2013;346:f652
When Lord Darzi was parachuted into the government in 2007 and asked to set the NHS on a new course towards greater quality of care, three outside bodies from the US were contracted to provide advice. But top managers did not like what they had to say.
There were claims that the NHS was characterised by a pervasive culture of fear, that “shame and blame” was embedded in the system, stifling innovation, and that patients were the last thing anybody ever took into account. But these were “a caricature,” declared Hugh Taylor, permanent secretary of the Department of Health, when forced to respond to the claims during the public inquiry into Mid Staffordshire NHS Foundation Trust in September 2011. Counsel for the department, Gerard Clarke, said that these were “broad and sweeping allegations about a supposed general culture” that the evidence the department itself had gathered did not justify.
Taylor’s dismissal of the findings as “overstated” and “pretty poorly evidenced” may not have been the best of judgments. While the reports were being commissioned in late 2007, the then health secretary denied the chief executive of Maidstone and Tonbridge NHS Trust, who had resigned after failings at her trust, an agreed pay-off in order to make an example of her.1 She later won a court battle to restore the payment, one of the Appeal Court judges remarking that the Department of Health had been willing to see her sacrificed “on the altar of public relations.”2
For David Nicholson, chief executive of the NHS, the fact that the most critical of the three reports into NHS care (from consultants Joint Commission International (JCI)3) “did not reflect the views of the Department stakeholders” was enough to damn it. “I do not accept that such a culture exists or existed,” he told the inquiry.
All three reports—one from JCI, one from the Institute for Healthcare Improvement (IHI),4 and one from Rand Corporation5—were stifled. They saw the light of day in 2010 only as the result of a freedom of information request from the think tank Policy Exchange. This was triggered by Brian Jarman,6 head of the Dr Foster Unit at Imperial College and one of the experts whose views the IHI had canvassed. The JCI report addressed quality oversight in the NHS, the institute report examined how to accelerate the pace of improvement of quality, and the Rand report looked at a narrower and less controversial subject, the development and dissemination of standards.
In cross examining Nicholson at the public inquiry into Mid Staffs, Tom Kark, counsel to the inquiry, reminded him of those whom the IHI had interviewed. “The chief executive of IHI is a man called Don Berwick, who is currently the administrator for the US Federal Centres for Medicare Medicaid,” he said, “and it was based on the evidence of, among others, Mark Britnell, who is director general of commissioning [at the Department of Health], Sir Nigel Crisp, Bernard Crump, Sally Davies, Andrew Dillon, Sir Ian Kennedy, Sir Bruce Keogh, and Martin Fletcher. So I don’t suppose you thought that report was insignificant, or did you?”
Nicholson gave no clear answer to the question but claimed that the IHI report and part of the JCI report had been influential in the Darzi review of NHS provision. However, neither is referenced in High Quality Care for All, the document in which Darzi set out his vision for the NHS, in June 2008. Nicholson’s actual reply was: “Can I . . . I mean, in terms of both the JCI and IHI reports can I . . . I mean, we commissioned them, you know, first of all. We asked the question and we knew we’d get a variety of answers to that question. The thing about JCI and IHI, of course, is that most of their experience is in another system—ie, a system that hasn’t got a system in the sense of it.” But he later went on to argue that the fact the authors came from another system was why they had been asked to carry out the reviews in the first place.
Taylor told the inquiry he couldn’t remember ever seeing the JCI report, but admitted the IHI report, though a caricature, was “as with all caricatures, not without its truth.” There was a recognition, he said, that the NHS reform programme led by the government had come across as a series of Exocets rather than as a well thought through, coherent programme. The department had put a huge amount of time and effort into supporting trusts in making some of the changes that were needed to deliver these sorts of improvements, he said, and this went unmentioned in the “litany” of criticisms in the JCI report. These changes included the Modernisation Agency (abolished by 2008) and national service frameworks.
Taylor summed up: “Now the nature of the NHS is that it’s a huge system and not everybody avails themselves of the kind of support and development which was available, but I just want to correct the impression that all the department did was set a target and shout at people until it happened.”
Culture of fear
JCI spoke to 50 “stakeholders”(though unlike the IHI it does not name them) and concluded that there was “a pervasive culture of fear in the NHS and certain elements of the department,” significant flaws in quality oversight mechanisms, weaknesses in data collection, monitoring, and use, a greater need for physician engagement and involvement, and problems with the management of trusts and the proposed regulatory legislation (the merger of three existing regulators to create the Care Quality Commission that was then in progress).
On culture, it said: “A ‘shame and blame’ culture of fear appears to pervade the NHS and at least certain parts of the Department of Health. This culture generally stifles improvement and the kinds of chief executive officer risk-taking behaviours that are necessary for creating organisation cultures of quality and safety. This culture is affirmed by Healthcare Commission leaders who see public humiliation and CEO fear of job loss as the system’s major quality improvement drivers. The culture appears to be embedded in and expanded upon by the new regulatory legislation now in the House of Commons.”
The IHI report, though more circumspect in its phrasing, reached much the same conclusions. Its authority is buttressed by the long experience Berwick has of the NHS—as Nicholson acknowledged, he had been a member of the National Quality Board. He might have added that Berwick is a strong supporter of the NHS (his contributions over many years have led to an honorary knighthood). IHI summarised the management approach of the NHS in England like this:
Add resources—an extraordinary investment has been made in the NHS, an unprecedented infusion of resources that is not sustainable much longer
Set targets and standards
Prescribe methods of meeting them
Manage performance to targets and standards through a fairly stern practice of executive accountability and, less formally, through the media and other forms of public embarrassment
Introduce competitive forces such as patient choice
If something goes wrong, or the newspapers get on the case, find someone to blame and punish him or her
If all else fails, restructure something.
Among other points made in the report was a failure to involve patients and families in improvement activities—a point highly relevant to Mid Staffs, where it was the protests of patients and their families that finally brought the problems into the open—and gaps between managers and clinicians.
Taylor conceded that the NHS hadn’t listened hard enough to people who complained about its services. “I think those of us who have been proud to be associated with the successes of the NHS in recent years would acknowledge that one of the areas where . . . it needs to do better is in listening to its patients, and to the patients and to the users of services, and not just to patients, but to those who care for them as well.”
As for the culture of fear and allegations of bullying, Taylor conceded only that there had been a strong emphasis on delivery and “robust discussions, from time to time properly challenging discussions.” Nicholson said: “I don’t believe there is a culture of fear in the way you describe it, and I don’t believe that because of the . . . I mean, I’ve worked . . . I’ve been in the department for the last six years. I’ve worked in the NHS extensively. I don’t, I’ve never recognised that way of describing it.”
The criticisms made in the reports were also put to David Flory, who was deputy chief executive of the NHS at the relevant time (he is now head of the NHS Trust Development Authority). “David Flory told us that he had not seen the JCI report when it came out and didn’t read it until it was brought to his attention by the solicitor to the inquiry,” Kark said in his final submission to the inquiry. “He told us he did not recognise the department which it portrayed. That may be thought to have demonstrated a lack of insight within the department, which was repeated by other senior officers. Sir David Nicholson told the inquiry he didn’t believe the JCI report was significant. Indeed, in general the department witnesses did not accept or even recognise some of the criticisms contained in the American reports, and yet many of those criticisms of a top-down and bullying culture were described by witnesses to the inquiry.”
The IHI report includes some anonymous quotations from those interviewed. One said: “Because of the fear of what will happen if targets are not hit, it’s not uncommon for managers and clinicians to hit targets and miss the point.” Another: “The risk of consequences to managers is much greater for not meeting expectations from above than from not meeting expectations of patients and families.” Or another, referring to the mistrust between managers and clinicians: “It’s good to set standards—to define what should be done, by the evidence. But it’s unprofessional to be told in detail how to get these things done, by people who don’t understand our community or our resources. When doctors are told what colour knickers they should wear on Wednesdays, they just tell the system to bugger off, and they should.”
The picture painted by the reports, by their non-publication, and by the response to them at the Mid Staffs inquiry is of top management of the NHS ignoring the criticisms that those slightly lower down the hierarchy were prepared to make to independent observers. What they saw as a caricature, others who gave evidence saw as an accurate if colourfully rendered portrait of a system that had lost its way. It is up to Robert Francis, chair of the inquiry, to decide who was right.
Cite this as: BMJ 2013;346:f652
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.