Filed Under (Accountability, Francis Report, Health Improvement, Health Policy) by Paul on 17-10-2012
A few weeks ago we learnt that the publication of the Francis Report on Mid Staffs will now be put off until January. In the interim there have been some concerns shared within the NHS about how the report might understand its world.
As Paul Hodgkin from Patient Opinion said at the conference I mentioned in Monday’s post, if the answer that the Francis report comes up with is ‘more regulation’, then they are probably asking the wrong question.
Earlier in the autumn Mike Farrar from the Confederation suggested that an increase in regulation was really not what the NHS needed and recently the Kings Fund published some interesting thoughts from their head of policy Anna Dixon about how the necessary improvement in quality in the NHS might happen.
We shall of course have to wait till January for the report and its recommendations, but again as Paul Hodgkin pointed out there have been previous enquires – for example Herbert Laming’s report on child abuse – which give us some glimpse of what might come out of any such report.
The Laming Report contained 108 recommendations and many of them were about tightening the regulatory framework within which statutory child care work takes.
More than anything else this form of recommendation springs from the nature of a Public Inquiry, from the fact that the public service disaster that has taken place, happened some time ago. Understandably the public wanted an Inquiry to find out what has happened – to stop it from happening again.
But given the passage of time the main reason that unsafe and dangerous practices in a particular institution occurred no longer applies. The staff concerned, and leadership of the institution, are no longer in post.
It is often several years later by the time an Inquiry reports. Given the staff and the leadership of the institution have moved on all that is left is the surrounding framework of regulation and, since something must be done, it’s the regulatory framework around the problem that must be changed and is almost always tightened up.
But the problem is that the reality improving quality and safety works the other way round.
As Anna Dixon pointed out quality and safety mainly depends upon the work and morality of front line staff. These are the individuals and teams of individuals who carry out the activities that form the core of care. Most people recognise that front line staff within a culture support safety and quality. But sometimes something happens to create a culture where this goes wrong in a systemic way.
That is why the second most important indicator for safety is the quality of leadership in the institution. Do they have the systems in place to notice that a part of their organisation has gone wrong? How do they review their institution to ensure safety?
I have been thinking about these issues because in a couple of weeks’ time I will be on a panel talking to hospital leadership about quality and regulation. Undoubtedly the last thing these hospitals want is a tightening of their regulatory framework. But for me there is a ‘quid pro quo’ of this.
In thinking about this discussion I have been working out a way to quantify responsibility for safety, and I reckon that over 90% of the responsibility for safety lies within the organisation. Most of that belongs to the professionalism of the staff and the rest with the leadership of the organisation.
Think for a moment what would happen if the percentages were the other way round. What would it feel like if 90% of the responsibility for safety lay outside the organisation? And what if within the organisation most of it lay with the Board? This would leave the front line staff feeling that they had very little responsibility and that safety was a matter for regulators a long way away from the front line.
Any such feeling would be disastrous for the health – or any – care service because it would create conditions where those who are literally ‘hands on’ in providing care felt that the responsibility for safety was mainly external to their actions.
Yet if the outcomes of inquiries concentrate mainly on what goes on in the regulatory framework, they are actively developing an understanding of responsibility for safety that is moving away from the front line.
If more inspectors inspect safety more often, it stops being a front line job and becomes the inspectors’.
This is not a helpful policy outcome in creating a higher quality health service.