Wednesday 20 November 2013

Only leadership will humanise the NHS

My nine-year-old came back from school yesterday evening in a cynical mood.  What had piqued his cynicism was the constant repetition, in rhetoric and on noticeboards, that his primary school is a 'Rights-Respecting School'.

"They say they listen to us and ask our opinions," he said crossly.  "They never do.  They just shout."

I have some sympathy with this, and the vacuous round of tickbox titles.  I also have sympathy with the institutional gap between rhetoric and reality in public services, and their capacity for self-delusion, and the conversation made me think of yesterday's NHS announcement.

The Department of Health has spoken and now we have a response to the Francis Report and all the others that followed the scandal of Mid-Staffs.  The answer is a flurry of measures and controls.

As so often, the influential NHS blogger Roy Lilley hit the nail on the head yesterday morning when he talked about the fear of the regulator, and frontline staff's fear of the managers, being greater than their fear of upsetting the patients.

On the face of it, these measures - forcing wards to declare their nurse-patient ratio, the duty of candour - are all sensible in themselves, but I am still nervous about them as a whole.  I don't want to take a high moral position on this - I don't have to run a ward or look after patients.  I don't have to balance the books of the NHS, but three things worry me.

The first is the Rights-Respecting-School conundrum.  This kind of rhetoric never seems to quite do the job.  Efforts via tick-boxes to make sure reality gets in line just seems to make the rhetoric even more vacuous, and the same I fear will happen to Jeremy Hunt's "safest healthcare system in the world".

You can't measure your way to that kind of objective, and here is my second worry.  On its own, forcing transparency on nursing levels seems a sensible move, but nurses seem scarce these days - because of the very battery of targets, standards, tickboxes and measures that this one adds to.

Separately, they seem sensible.  Together, they amount to the very hollowing out of moral purpose that caused Mid-Staffs in the first place.

The third worry follows on from this.  Policy-makers have grasped that targets can damage the fabric of public services.  What they have yet to grasp is quite how much of the energy and attention of the organisation gets shifted, by managers and frontline staff alike, into managing and massaging the figures.

They have yet to understand what a disaster the targets culture has been for our services (see latest news about police statistics).

Years ago, the author of The Audit Explosion, Michael Power at the LSE - writing at the very beginning of public sector targets - talked about the irony that any failure of accounting was tackled by more accounting.

That is what seems to be happening here.  Every failure of iron control is tackled by ratcheting up the pressure: more measures, bring in the police, legal duties - at this rate we will be jailing health staff.  Maybe there will occasionally be justification for doing so, but what about their managers, what about the board, what about the policy-makers who designed the system that made these horrors possible?

What would I do?  Well, here are two things.

First, I would humanise the wards by turbo-charging volunteering by patients, their families and their neighbours.  Volunteers who work alongside staff are immune to the kind of pressures that are brought to bear on paid staff, and they act as a major humanising force.

Second, I would sack the boards of hospitals which make these kind of scandals possible.  It isn't a solution, but it is a bare minimum that those who took the decisions at the top should be held responsible.

But in the end, the main thing that will shift the problem is inspirational leadership at local level, and at ward level.  That is tough to achieve when staff at every level are motivated primarily by fear, and have had leadership leeched out of them by a generation of disastrous targets and detailed central control.

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