Do official inquiries and reports make any difference to how we run and regulate the NHS? It’s a year since Robert Francis published his findings following the high profile failings at Mid Staffordshire, where shocking care and neglect became all too apparent.
Whether all these reports, and Francis in particular, have an impact on how the NHS is run is important. Reporting on the failures and reforms of healthcare organisations is part of how we go about governing the NHS. And a new report published by Nuffield today – essentially a report on a report – considers what has changed in the NHS since the Francis Inquiry.
Since Francis we’ve had Bruce Keogh on mortality rates, the cosmetic surgery industry, and emergency care; Don Berwick on patient safety, Camilla Cavendish on healthcare assistants and support workers, and Jane Cummings on compassion – and there are more.
Mid Staffordshire happened because of terrible organisation failure and consequences surely had more than a shocking effect on the way hospitals are managed and audited in England. Francis was called a turning point after all. So why do we revisit it one year on?
It’s hard to predict the reactions to a report and not all carry the same weight. And even when they do, organisations such as NHS trusts are part of other regulatory schemes that make it difficult to effect change and it may also be near impossible for managers, however willing, to exert full control over the quality and cost of services they look after and the organisation’s culture.
Reports (and the counter publications that react to them) have an essential role in communicating thinking about an issue, raising awareness and pinpointing changing priorities, but if they don’t change the culture in an organisation then what is the point? The failings they identify are only likely to be repeated. Knowing what is wrong is great, but not if we don’t do anything about it.
‘Unresolved dilemmas’ in Francis
The Francis report made 290 recommendations, including a call for a duty of openness among NHS staff. But there are two “unresolved dilemmas” in the way healthcare organisations like trusts are run and managed that I think stand out:
How do you make savings without hampering quality of care – especially when quality means “objective quality”, so not just perceived satisfaction but the actual deterioration of outcomes for patients, such as death and recovery rates?
How do you identify and prevent procedures and professional behaviour that are close to being negligent and are part of the norm? Organisational failures often result from practices that are hard to identify, both by insiders (because they see it day-in-day-out) and outsiders (because they’re not there long enough to notice).
Incentives should target quality
In the Nuffield report, senior NHS staff said Francis had given impetus to their efforts to put care quality first. But it also found that financial pressures and a complex regulatory system are making it difficult for hospitals to create a culture where patients come first. It comes as one in three hospitals trusts forecast they will be in the red by the end of the financial year.
The first financial dilemma suggests that excessive financial pressure comes at the cost of lower quality of care. That is, quality isn’t accounted for when financial incentives are set. When it comes to capitation payments, for example, healthcare providers are paid for each enrolled patient rather than the amount of care they give to those patients.
Of course, it is hard to predict how new financial incentives will affect an organisation. Initiatives to improve quality include ratings for trusts, publishing performance and highlighting best practices and so forth. But these are often not accounted for in the allocation of funding. So together with limited social incentives to quality, there are also limited financial incentives too.
Many organisations subject to financial pressures, put more weight on social incentives instead. Examples include motivating certain employees (nurses and midwifes, for example) to attain certain professional standards. Reducing the hierarchies within trusts and hospitals, for example, could allow information to flow more freely. And this leads us to the second dilemma, that of organisation culture.
Culture is not independent
Every organisation works within external restrictions, such as regulatory systems and commissioning services, as well as an internal set of norms and procedures that we call “culture”. And these aren’t independent of financial rewards. Organisational culture, as Francis rightly identified, is important because it is hugely important when it comes to safety. But a lack of financial rewards affect organisations as a whole and the effects often trickle down the ladder. If our aim is to improve the overall efficiency of the system then quality needs to be at the core of any incentives, not just cost alone.
But on the flipside, we know that excessive use of financial incentives can crowd out professional culture (or duty) to a certain extent and in doing so have a counterproductive effect.
So do reports work?
It is fair to say that reports are just messengers. But messages are hardly ever found in one report alone but in the wider debate that they create on how best to address the key challenges of delivering healthcare. The Francis report and the report-on-the-report one year on consider the dilemmas inherent in the system, which we still have yet to answer: with financial pressures and cost-savings to be made, can we really change how we do things? There will no doubt be more reports on this to come.