The first limb of the Government’s initial response focussed on “preventing problems”. Meeting this objective entails bringing about a cultural change at all levels of the NHS. Is this achievable?
One of the criticisms of Mid-Staffordshire NHS Foundation Trust was that the focus was on the wrong things. It was on “hitting the target and missing the point”. The Government accepts Francis’ view that a cultural change is required and has sought to outline a series of measures to “revitalise the culture of the NHS around a consistent focus on the needs of the patients it serves”, never losing sight of the core values of compassion and care.
While acknowledging that every team will have its own distinct culture, the Government agrees with Francis’ conclusion that the common values and cultural attributes that should be fostered across the NHS should be set out in the NHS Constitution.
In March 2013 a revised Constitution was published. This was accompanied by a revised Handbook. That is not the end of the matter. There is to be yet more consultation on the Constitution this year to respond more fully to the Francis recommendations. The principles as currently state as follows:
- The NHS provides a comprehensive service, available to all
- Access to NHS services is based on clinical need, not on an individual’s ability to pay
- The NHS aspires to the highest standards of excellence and professionalism
- The NHS aspires to put patients at the heart of everything it does
- The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population
- The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources
- The NHS is accountable to the public, communities and patients that it serves
Even at the present juncture, many have argued that the government has missed an opportunity. While the Constitution has no doubt been strengthened, the seven key principles have not been written with the robustness of language that one would have expected. After all that has been said by Francis the fourth principle is unfortunately phrased in the tenor of an aspiration.
Within the core values it is stated that “patients come first in everything we do” so it is a mystery why the principle uses the aspirational and less robust language. However, to stem the criticisms that followed the re-drafted NHS Constitution, Jeremy Hunt, SoS for Health, has confirmed that there will be another round of consultations later this year on changing the constitution.
Be that as it may, the current version is much enhanced and the spirit and message is clear – putting patients first, and creating and maintaining the right culture to deliver high quality care that is responsive to patients’ needs and preferences. It takes more than a revamped Constitution to bring about a cultural shift in attitude.
The Kings Fund has identified a number of factors that characterise a good culture of care1. These include:
- developing a clear vision for quality
- supporting staff to deliver the best care
- Boards developing the right culture
- responsive to patients’ needs and preferences
- an open and just environment
- adopting the right leadership styles
- thinking and acting long term
Tim Scott et al in their article Implementing culture change in health care: theory and practice’2 note the following barriers that block purposeful change:
- lack of ownership – unless a critical mass of employees ‘buy into’ a culture change programme, such initiatives are likely to fail
- complexity – successful strategies require realistic timeframes to implement the types of complex and multi-level changes required
- external influence-the influence of outside interests may sometimes work against efforts towards internal reform.
- lack of appropriate leadership – appropriate leadership not only modifies familiar behaviour, but redefines interpretations and experiences of health care.
- cultural diversity – a key challenge to culture change programmes is to consider the impact of change on specific groups (doctors, nurses and other health professionals) and to design appropriate policies to accommodate this.
- dysfunctional consequences – cultural change policies can bring a range of unintended consequences. Increased focus on performance targets has resulted in a concentration on areas that are measured to the detriment of others, concentration on short term issues, misrepresentation of data.
Other key tenets
Central to the Government’s desire to bring about a cultural change is the creation of the role of the Chief Inspector of Hospitals. He or she will "shine a powerful light on the culture of hospitals, driving change through national ratings which put the experience of patients at their heart". The Chief Inspector will provide oversight to the Care Quality Commission’s inspections, assessments and ratings of providers and will communicate findings to the public. In reality the evidence will come from the team of highly skilled and trained inspectors on the ground, supported by data about complaints, whistleblowing, patient experience and staff experience. They must be given the resources to undertake their functions, but must also truly understand the DNA of the NHS, to engage in a shared language with NHS managers and report back in a manner that shows an understanding of findings and clear objectives for improvements where appropriate.
The new commissioning landscape put in place during the recent reforms is also expected to safeguard patient care and respond to many of the concerns highlighted by Francis. Clinically led commissioning, together with the new role of health and well being boards should provide a platform for partnership working thereby improving outcomes for the whole population. Without a doubt this is a significant cultural shift in the way the health system is managed, but is also risks inconsistencies across the national piste. A CCG which works well with its other stakeholders (including patient groups) will drive through these cultural changes, whilst others may, again for deep seated cultural reasons, not manage to bring about the required change.
In the studies quoted above, the importance of ‘buy in’ from staff was highlighted. This has been recognised by the government. The government’s response makes it clear that Board behaviour and leadership, (including how they engage those they lead to ensure that they are not unsupported) will be a key focus for the Chief Inspector of Hospitals.
NHS providers are promised a working environment "unconstrained by a culture of bureaucratic compliance with national regulations", with "paperwork, box ticking and duplicatory regulation and information burdens" reduced by at least one third. The NHS Confederation will be undertaking a review of bureaucratic burdens on NHS providers and will report in September 2013.
Zero harm is an aspiration embedded in a culture of safety. At the end of July we expect to receive the report from the National Patient Safety Advisory Group led by Don Berwick into a whole system approach to make zero harm a reality in the NHS. The key stakeholders will then consider how to take this forward. The NHS CB will develop and deliver a revised and responsive National Reporting and Learning System to provide a single place for the NHS, clinicians, patients and the public to report patient safety incidents and receive advice.
All of the above taken collectively will drive the Government’s agenda on openness and transparency. Others have written about the statutory duty of candour and the possibility of criminal sanctions. The scale of the shift in culture required to turn these aspirations into reality and to prevent another Mid-Staffordshire is immense. It depends not on the Government’s response per se, but on the willingness of each provider, commissioner, regulator and user to believe that change is possible. The picture is not completely bleak as there are some NHS bodies that already embrace the tenets of change. Others, have some way to go. Mid-Staffordshire must cease to be an example of failing, but the barometer that brought about change.