Mid Staffs and top down bureaucracy

The failings of the Mid Staffordshire NHS Trust are nothing short of a scandal. Poor care at Stafford Hospital has been linked to hundreds of deaths. Yesterday’s Telegraph reported that the management team in charge during the mess will not be disciplined; indeed some will receive handsome pay-offs. The former (‘by mutual consent’, naturally) Chief Executive of Mid Staffordshire NHS Trust actually featured on our Public Sector Rich List, earning up to £160,000 in 2008-09. If no managers, board members or others responsible face sanctions then who is to blame?

After several reports from regulators, an inquiry for the Department of Health released its findings yesterday. According to the inquiry, this isn’t one of those straight-forward failures when staff are blameless, hindered from doing their frontline jobs by a bureaucratic machine. It says that many were uncaring, and management were in denial about the failings at Stafford Hospital. Of course, a lot of of the staff did their best in trying conditions but it’s clear that the attitude of some was unforgiveable.

But this is the NHS, so the bureaucratic machine was (and still is) very much in existence, as the report confirms:

“What this investigation has uncovered is failure on a scale that cannot be adequately expressed in statistics – indeed, over-reliance on figures has been one of the reasons for the Trust’s failings...”

The report finds that the Trust put ratings and setting up ‘systems’ ahead of patient care:

“A common response to concerns has been to refer to data, often of a very generic type such as star ratings, CNST levels and so on, rather than to the experiences of patients and their families... While structures are an important and necessary part of governance, what is really important is that they deliver the desired outcome, namely safe and good quality care. There is evidence that setting up systems predominated over improving actual outcomes for patients...”

This sad and outrageous case represents the very worst of the ‘target-setting’ and ‘box-ticking’ culture that pervades many government departments, let alone the rest of the NHS. Andy Burnham may be defending this approach – as ministers from other departments have done in the past – but even he cannot deny that this top-down method of improvement has had tragic consequences in Mid Staffordshire. Moreover, this scandal makes a mockery of the bureaucratic structure established over the past decade, which prioritises ‘financial’ management over patient care: Monitor, the Government regulator of NHS Trusts, made Mid Staffs a Foundation Trust in the middle of this scandal. Sound financial management and patient care can – and should – go hand in hand. It’s not a choice between one or t’other.

The solution to this should not and cannot be more regulation and ‘investment’. Indiscriminately throwing yet more money at the NHS will not cure its ills. Including planned spending for 2010-11, the NHS in England has been funded to the tune of £660 billion since the 2003-04 financial year – almost £100 billion per annum. After so much investment, ring-fencing its budget is no solution either. Healthcare in Britain fails to match up to the standards of its European neighbours – as our report Wasting Lives found – and not because it is underfunded. Our system is too centralised, overly-managed by politicians and too inured to competition. As this case emotively proves, patient welfare doesn’t always come before targets. That costs lives.

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