Welsh NHS needs more professional leadership

Malcolm Prowle asks what Wales can learn from the scandal unveiled in Mid Staffordshire

The report on the Mid-Staffs NHS Foundation Trust makes appalling reading. Worryingly, there is some evidence to suggest that this is not an isolated case. The media has reported that five other hospital trusts are to be investigated over their mortality rates following the publication of the Mid-Staffs report. Furthermore, a report in a Sunday newspaper stated that a firm of solicitors is representing relatives and patients with regard to legal action at ten NHS Trusts. If this is the case then we cannot just dismiss Mid-staffs as an aberration but we must look for more systematic causes and solutions.

It would be naive to imagine that the Welsh NHS is immune from these sorts of problems and indeed the Lib-Dem leader in the National Assembly, Kirsty Williams, has already warned of the risk of a scandal similar to Mid-Staffs. So a key question is what Wales can learn from the Mid-Staffs report?

In spite of the length of the inquiry and the efforts put into to it by the inquiry team in coming up with 290 recommendations, I am not convinced it really hits the nail on the head and comes up with workable solutions. At first glance, the inquiry report is correct when it talks about the need for fundamental change and shifts in attitudes and culture in the NHS. However, where is the evidence that the cultural changes needed will be achieved by legislation, criminal charges, regulation, inspection, greater Ministerial supervision and other controlling methods? Changing cultures is much more subtle than that.

Firstly let us deal with the resource issues head on. I find it difficult to believe that patients being forced to drink water from flower vases and lying in soiled sheets for many hours is a consequence of financial pressures. In many years over the last decade the NHS has had record growth in resources and more modest growth in other years. Furthermore, between 1997 and 2006 the Royal College of Nursing’s own figures show that the numbers of qualified nurses in the NHS grew by 25 per cent in England and around the same in the rest of the UK including Wales. Can we really believe that this sort of behaviour can be put down to ‘lack of resources’ or ‘pressure of work’? I know from personal experience that there are many dedicated and hard working professional nurses but am I the only person to have noted in some hospitals  nurses sitting at the central station in a ward chatting or texting while alarm bells are ringing? It looks more to me that a lot of the problems of Mid-Staffs can be put down to a lack of proper professional leadership in the nursing profession not shortage of resources.

Secondly there is the role of effective financial management and control in an NHS Trust. The inquiry report comments that it was the board which took the decision to pursue a cost-cutting drive to achieve foundation trust status and it was the board which refused to listen to the complaints of patients and – at times – staff. Now whether the board went too far in a drive to cut costs I do not know, certainly a balance needs to be struck between the delivery of services and effective financial planning and control.

The reality is that NHS Trusts have finite resources and have to deliver services within that resource constraint. This problem will not go away, no matter how many inquiry reports are produced. The danger now is that NHS Trusts will go too far in the other direction and take decisions resulting in huge financial overspends. This is particularly a concern at present in a period of financial austerity where NHS Trusts are having to identify large scale savings. Research I have recently completed on financial governance in NHS Trusts suggests that there are significant weaknesses in NHS financial governance which will be exacerbated by the pressure of austerity.

I would also focus on the relationships between managers and health care professsionals in the NHS. In my 35 years of experience of the NHS it seems to me that this relationship is at best, somewhat distant and at worst antagonistic and lacking in trust. Health care professionals often see NHS managers (or administrators as they prefer to call them) as ‘the enemy’. They see them as collaborating with government to deny them the resources they need to treat patients as they think fit.

On the other hand, NHS managers often see health care professionals as unwilling to accept the realities of finite resources, defensive about their own professional status and practices and unprepared to fully engage in the decision making process as to how resources should best be used. Anyone who doubts this situation exists should have a look at TV programmes such as Casualty or Holby City to see how NHS managers are portrayed.

This week I heard a debate on the radio about the NHS which involved a number of health care professionals and a politician (no, there was no NHS manager invited). As usual, the cry came up for a greater involvement by healthcare professionals in decision making in the NHS. Similar arguments were heard at the time the Health and Social Care Act 2012 was going through Parliament and indeed subsequent changes were made to take this on board. I actually think most NHS managers would welcome such increased involvement and engagement by health care professionals provided they accepted the realities of finite resources and were also prepared to be fully accountable for those decisions that they were involved in and would not stand on the side-lines carping.

It is essential that cultural change takes place in the NHS, including the Welsh NHS,  if we are to avoid repeats of the sorts of scandal found in Mid-Staffs. However, I am not convinced that the inquiry’s recommendations are the way forward. There has been much written about how organisational cultures can be changed and the first thing to say is that it is difficult. The other thing we could do is heed the words of John Kotter, perhaps the leading global expert on cultural change in organisations. He makes a number of key points:

  • What is the nature of the problem? Virtually no one clearly defines what they mean by ‘culture’, and when they do they usually get it wrong. Secondly, virtually no one has read the original research that shows why culture, when clearly defined, is so important, how it is formed, and how it changes.
  • How does culture change? It changes by a powerful person at the top, or a large enough group from anywhere in the organization, deciding the old ways are not working, figuring out a vision for change, acting differently, and enlisting others to act differently. If the new actions produce better results, then this is communicated and celebrated, and if they are not killed off by the old culture fighting its rear-guard action, new norms will form and new shared values will grow.
  • What does NOT work in changing a culture? Drafting a list of new values which are passed to the PR or HR departments with the order that they tell people what the new culture is. They cascade the message down the hierarchy, and little to nothing changes.

Which path to cultural change will the NHS in Wales take?

Malcolm Prowle, who lives in Wales, is Professor of Business Performance at Nottingham Business School and a visiting professor at the Open University Business School.

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