Jeremy Hunt was right last week to talk about no stone being left unturned in the improvement of patient care. The Francis reports have, rightly, changed the game: the NHS can no longer focus on balancing finances and meeting access targets (important though these are) at the expense of patient care.
Last week’s announcement on the special measures regime began to explore what the NHS should do when quality falls below required standards and what makes an effective quality failure regime.
‘No one can or should defend unacceptable standards of care and we must err on the side of protecting patients rather than trusts’
First, we need a rigorous, independent, credible and carefully calibrated way of identifying quality failure and a system of consequences to follow. This isn’t as easy as it sounds. The old Care Quality Commission inspection regime was clearly not fit for purpose, and while the new version is shaping up well, many will suspend judgement until they see how well the new system works. Independence is vital: any sense of the failure regime being driven by political or other considerations would be fatal to its credibility.
We also have a calibration issue to solve. I was struck by the number of chief executives I spoke to who, on reading the Keogh review, thought: “There but for the grace of God…”
No one can or should defend unacceptable standards of care and we must err on the side of protecting patients rather than trusts. There are also a small number of trusts that have consistently struggled to meet a range of national quality standards, and Jeremy Hunt is right to say that these need to be publicly identified and improvements made.
Yet, as the Foundation Trust Network has already stated publicly, pockets of poor care can exist across all types of trust at various times, including in the very best trusts who manage risk well. This is very different to “consistently struggling to meet a range of national standards”. Based on the evidence of the Keogh review, trusts are concerned that they now risk being tipped into special measures without clarity about where the bar is set and about what consequences will follow.
‘We need, for example, to be wary of requiring trust boards to accept particular forms of help that come with powers that cut across their accountabilities’
So as we focus much more on quality, we need an agreed and appropriately calibrated scale of failure and resulting consequences, stretching from the events at Mid Staffordshire at one end to an isolated incident in a single setting at the other.
There is also an important issue around public communications. There will be understandable pressures on NHS system leaders to “name and shame” the places where poor care is found, not least to show that they are driving rapid improvement. But the Berwick review rightly highlighted the need “to abandon blame as a tool and trust the goodwill and good intentions of all NHS staff”. He added that “fear is toxic to both safety and improvement” − the two keystones of the new NHS culture we need to create.
Moving on to how we improve care, the FTN has always believed that NHS improvement models should draw more heavily on existing expertise within the sector, rather than management consultancy or the top-down, centrally driven models that have marked the service’s traditional approach to improvement. So we welcome the idea of the best trusts supporting improvement where it is needed.
However, accountability for improving performance in a trust is not the responsibility of these buddies, nor of commissioners, Monitor, the Trust Development Authority, the local NHS England area team or the secretary of state. It can only be the responsibility of the trust board and we blur that accountability at our peril.
‘An effective failure regime isn’t about putting failing trust leaders in the dock’
Again, in Don Berwick’s words, “When responsibility is diffused, it is not clearly well owned: with too many in charge, no one is.” We need, for example, to be wary of requiring trust boards to accept particular forms of help that come with powers that cut across their accountabilities. Either a board is in charge, or it isn’t; there is no halfway house.
We also need to be careful about assuming that failure is solely a product of the individual institution. Most failing trusts tend to sit within failing wider local health and social care economies. A model that concentrates solely on improving individual trust leadership, without tackling the underlying wider structural issues and ensuring the whole system can work together effectively, is likely to fail.
Given the clear links between financial and quality failure, we need to work out how to address the growing number of trusts that will become clinically or financially unsustainable as the financial squeeze bites and they are unable to reconfigure their services quickly enough.
An effective failure regime isn’t therefore about putting failing trust leaders in the dock to enable system leaders to demonstrate how effective they are. It’s about supporting trust boards to find the right solutions to what are usually complex, long established, system-wide, problems.