Thursday 7 February 2013

Why the Francis Report doesn't cut the mustard

Julia Neuberger has had a varied career, as a rabbi, as a Lib Dem peer, in the health service and as Gordon Brown’s volunteering tsar.  But she provided a fascinating insight into why some institutions feel human and some don’t, and it could do with revisiting in the light of yesterday’s Francis Report on the Mid Staffs Hospital scandal.

In her book about older people, Not Dead Yet  she described how her uncle was neglected in three of the four hospitals in which he lived his final weeks.  She explained that the one exception was also the hospital which was most cash-strapped:

"When my uncle eventually died, in the hospital which really understood and respected his needs and treated him like a human being, there were volunteers everywhere.  In contrast, there was barely a volunteer to be seen in the hospital which treated him like an object, although it was very well staffed.  At a time when public services are becoming more technocratic, where the crucial relationships at the heart of their objective are increasingly discounted, volunteers can and do make all the difference.”

She was writing shortly after the Mid Staffs deaths first came to light, and suggested that volunteers might be an antidote.  In wards where older patients might otherwise be mistreated or ignored, she said: “the mere presence of older volunteers are the eyes and ears that we need.”  Human beings provide that kind of alchemy, however target-driven the institution is around them.

It isn’t quite clear why this is.  Is it because the presence of outsiders is a reminder to staff of what is important and how to behave?  Is it because it stops them getting too inward-looking, or prevents that brutal contempt for customers that – as we have seen – can emerge in target-driven organisations, public and private?  I don’t know.  

So I thought about Julia's uncle again when the Francis Report came out yesterday, because the question of how to humanise some hospitals – those which have had aspects of their professionalism and humanity surgically extracted – is at the heart of the problem he is trying to solve.

Having volunteers on the wards, working side by side with NHS staff is a critical part of the solution.  Having patients and relatives there isn’t enough – that remains an 'us and them' relationship.  So does having volunteer regulators or patients sitting on boards.  Same problem.  But patients working alongside staff to deliver the services does seem to humanise.  That is why the co-production agenda is absolutely critical.

But I am still sceptical about the Francis Report, and for the same reason it is hard not to be sceptical about Sir David Nicholson’s media performance yesterday – the list of solutions is too long, the list of measures the NHS is already taking is just too labyrinthine.  They are both too ambitious and not nearly ambitious enough.

None of them quite seem to nail the real issue at the heart of this, which is a big one.  It is this: over the past generation, we have systematically taken the soul out of the organisations we depend on, with targets and tickbox systems and procedures, encouraged by the big consultancies - and McKinsey particularly - that organisations are great big humming machines which can be managed by numbers (McKinsey's slogan: everything can be measured and what can be measured can be managed (it is nonsense)).  That is a far bigger problem than whatever happened at Mid Staffs, though up to 1,200 dead is a big enough reason to take this seriously.  That is why Mid Staffs may actually be the tip of the iceberg.

Cameron was right that we need to bring back a sense of responsible professionalism.  Of course we need to put patients first (strange that it has to be spelled out).  Francis recommended a range of important measures; changing the shape of hospital boards, making one senior manager responsible for patient care.  But we also need to recognise that all our public services have been hollowed out in the same way.  So have the regulators: they date back to the New Labour era, where McKinsey's slogan ruled - they are structured for tick-box inspections.

So the Francis Report may have added a nail to the coffin of targets and tick box procedures, but it has not yet slain the monster.  The government is cutting back on targets, but the regulators are not – and we are also introducing a new generation of targets in the form of  payment by results contracts (basically numerical targets with rewards attached).  They all undermine professionalism and effectiveness because they reduce success to one-dimensional measures.  They spread inhumanity.  They also spread failure.

So when Nicholson talks about the two million people who are members of foundation trusts, you have to ask if this membership has any depth.  What do they do?  How exactly do they hold professionals or boards to account?  None of this was included in the original legislation and it remains unfinished business.  Julia Neuberger's story, and my experience too, suggests that their influence will be felt with patients 'doing' stuff not 'saying' stuff.

What the Francis Report does do is to put effectiveness on the agenda.  Because, in the end, this is about whether or not our organisations have become too stupid to make a difference.  It isn't just about deaths, though that is the core issue.  It is about making things happen, and how the ability to do this slipped through our fingers with vastly expensive reforms which were supposed to bring accountability – but have actually torn the heart out of our organisations, in more ways than one.

1 comment:

Liberal Eye said...

Yes, targets and tick-boxes are a big part of the problem. Over at LDV I have made some concrete suggestions as to what should be done in response to Norman Lamb's post. For the moment it's held in moderation - no doubt because it was written with some passion.