New Public Management applied (1) The NHS

Foundation Trusts

The English NHS is controlled by the UK government through the Department of Health. NHS England commissions various types of organisation to provide NHS services, including NHS trusts and private sector companies. Since 2002, many NHS trusts have become NHS foundation trusts.

As part of the government’s drive to devolve responsibility, NHS Hospitals were asked to move towards Foundation Trust status, giving them an independent legal status and greater financial freedoms, largely so that performance would be rewarded financially, and failings would be the responsibility of the Trust, not of the government.

When a Foundation Trust is being set up, the criteria being measured for financial reward do not include such issues as quality of service for the patient  – even though as any intelligent person would point out, in a hospital quality of service is critical. Indeed it can quite literally be a life-and-death matter.

The result is that Foundation Trusts are not being incentivised to do the work they were set up to do. The incentives are focused far more on getting people to meet procedural and numerical targets than they are on achieving standards of care.

The case of the Mid-Staffordshire Foundation Trust

Cannock Chase Hospital, Part of the Mid-Staffordshire Hospital Trust

In 2007, The Mid-Staffordshire Trust was showing death rates dramatically higher than elsewhere in the UK. The West Midlands Strategic Health Authority commissioned an investigation. The result blamed the data, not the quality of service and nothing was done*.

Indeed The Trust’s application for Foundation  status was accepted in 2008 and it was rated as ‘good’ for the quality of service and ‘good’ for the use of resources for the year.

In spite of this, the Healthcare Commission was becoming uneasy. They had good reason to be. Their 2009 report into high morality rates at the Mid-Staffordshire suggested that up to 1,200 patients had died needlessly between 2005 and 2008. As the Daily Telegraph reported,

“Hundreds of patients died amid appalling conditions, starving on the wards, thirsty and in soiled bedclothes. Some patients were left so dehydrated that they began drinking from flower vases. Patients' buzzers would drone endlessly, unanswered.” [1]

Four years later, in 2013, Professor Norman Williams, the president of the Royal College of Surgeons said that managers at the Foundation Trust were so focused on hitting financial and waiting-time targets that they “forgot why they were there”. He said that surgeons were still under pressure to operate on less urgent cases, in order to clear the waiting list and ensure patients did not breach the 18-week target from time of GP referral to treatment. And lest anyone believe that Mid-Staffordshire was unique, he went on to emphasise that what happened in Mid Staffordshire was happening elsewhere too. [2]

The Francis enquiry of 2010 into this catastrophe and the public enquiry that lasted from 2010 to 2013 tended to cover up rather than reveal significant evidence, as Geoffrey Rivett, the authoritative historian of the NHS, suggests:

“While Francis said that, ‘the public are entitled to expect leaders to be held to account effectively when they have not applied the core values of the Constitution,’ and the report criticised the work of the strategic health authorities which oversaw Mid-Staffordshire Foundation Trust, it included little direct criticism of specific leaders and seemed to many to fudge the extent to which supervisory organisations had proved impotent. It was said that the draft report had been edited to remove unhelpful criticisms.” [3]

Robert Francis QC presenting the 1700 word report

In his letter to Jeremy Hunt,  the Secretary of State for Health, Francis writes,

“Above all, (the Trust Board) failed to tackle an insidious negative culture involving a tolerance of poor standards … This failure was in part a consequence of allowing a focus on reaching national targets, achieving financial balance and seeking foundation status to be at the cost of delivering acceptable standards of care” *

It clearly did not occur to Francis that ‘acceptable standards of care‘   should have been included in the national targets  or been part of the criteria for achieving foundation status.

The final report made 290 recommendations, all very well-intentioned. These ranged from “The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance” to “The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level possible.” There were no incentives offered to encourage people to follow these recommendations, and, in fact whatever effectiveness the recommendations might have had was compromised when the Health Minister questioned many of them.

It was not until 2014 (and then only because the Trust had failed to hit its financial targets) that the Mid Staffordshire Foundation Trust was dissolved.

Ignoring the evidence

At leadership level there was, as Rivett says,

“An underlying naive belief that regulation could guarantee quality. In short order three quality regulators replaced each other, CHI, CHAI (the Healthcare Commission) and CQC. Each fell short of expectations but the obvious conclusion that regulation alone could not be relied upon to guarantee quality seemed unclear to those concerned.” [4]

The result, he continues, was that these regulators:

“All imposed discipline on managers that resulted in pressure on staff to conceal and work round difficulties that could seldom be solved within existing budgets and staff numbers. Assurance that ‘all was well’ now became a priority. Commissioners and providers could not afford to risk becoming the next Mid-Staffordshire. [5]

Not only was evidence suppressed; lessons that could have been learnt were not. For example, as late as 2012, two years after the Francis enquiry into the catastrophe at Mid-Stafford, PricewaterhouseCooper produced a presentation for the NHS to show Health Trusts what they needed to do to become Foundation Trusts. In the entire 22 page presentation, only one  page  sets out criteria to be met. The other pages describe processes and procedures to be followed. Of the 12 criteria, not one mentions quality of service.**

It is hard to believe that for more than three years no-one among the 3,000 employees of the Trust was aware of what was going on. It is hard to believe that the managers could choose to turn a blind eye to the unnecessary deaths and suffering. It is hard to believe that the Independent Regulator did nothing when this came to light, but acted only when the financial targets were missed. It is hard to believe that so few lessons were learnt.

Above all, it is hard to believe that Cochrane’s revolution had been corrupted to such an extent in such a short time. I would argue that this is the kind of behaviour one would expect from adherents to a cult.


[ Next Measure for Measure: New Public Management and Policing ]

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* Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (February 2013)

The Statioery Office, London

**

Screen from a 2012 PowerPoint presentation: “Becoming a Foundation Trust“* [6]

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[1]  Donnelly, Laura.  "Stafford Hospital: the scandal that shamed the NHS" at http://www.telegraph.co.uk/news/health/heal-our-hospitals/9782562/Stafford-Hospital-the-scandal-that-shamed-the-NHS.html.  Telegraph.co.uk January 6 2013, accessed February 2 2015
[2]  Smith, Rebecca.  "'Target culture' that led to Mid Staffs still exists in NHS, claims top surgeon"  at http://www.telegraph.co.uk/news/health/news/9824256/Target-culture-that-led-to-Mid-Staffs-still-exists-in-NHS-claims-top-surgeon.html  Telegraph.co.uk.  January 25, 2013.  Accessed March 2 2015 
[3]  Rivett, Geoffrey.  "Chapter 7 2008 to the present An uncertain path ahead"  National Health Service History , at http://www.nhshistory.net/chapter%207.htm#Quality. 2015  Accessed April 9 2015 
[4]  idem
[5]  idem

[6] Pricewaterhousecoopers "Becoming a Foundation Trust" at http://www.england.nhs.uk/wp-content/uploads/2012/06/Becoming-a-Foundation-Trust-What-are-the-issues-for-CCGs.ppt, June 1 2012 NHS England, accessed April 15 2015