At the heart of the care scandal in Mid Staffordshire foundation trust and the Baby Peter case is the need for a strong culture of questioning and scrutiny
They are different places and their failures had different consequences but both Haringey borough council in London and Mid Staffordshire foundation trust have been through chastening experiences this year.
The pattern is one familiar in health or social care scandals. First the problems, exposed and reported. Then investigation, apologies and, ultimately, sober pledges that “lessons will be learned”.
One factor crops up repeatedly in the analysis of the problems - a lack of curiosity
It is striking to see the similar catastrophic shortfall in standards at Haringey, in the death of Baby Peter, and at Mid Staffordshire, where the Department of Health said a Healthcare Commission investigation published in March had found “a catalogue of appalling management and failures at every level”.
One factor crops up repeatedly in the analysis of the problems at both organisations - a lack of curiosity, both internally and externally.
A successful organisation is one where the board is endlessly curious and challenging in fulfilling its ultimate responsibility for performance.
Successful boards have a daily hands-on role because they want to know more about their staff, customers and business and how these compare with other organisations.
Real time feedback from users, complaints and incidents are valued. With this comes a desire to innovate; to compare and challenge processes, cultures and decisions.
The multiple reports into both Mid Staffordshire and Haringey demonstrate clearly that elected members and non-executive directors relied on process driven reporting, which told them their organisations were working well, but lacked a good understanding of the daily issues frontline practitioners and users faced. A culture of curiosity and challenge, fostered from the top level, should have encouraged them to hold staff to account and ask difficult questions.
The NHS Confederation has recommended voluntary peer review by the NHS as a way of sharing best practice and bringing outside scrutiny to bear on boards. This is already in place in the best of local government, but perhaps should be used across whole local systems.
This is not a replacement for formal scrutiny but a reminder that what counts is the experience of patients, users and the public by examining curiously how others achieve high quality.
Emphasis on targets
What was also clear from both of these cases is that middle managers should have felt able to take responsibility for their workload.
Both organisations had problems with unfilled vacancies, which put pressure on the managers they did have, and both placed too much emphasis on targets and too little on well supported, benchmarked professional judgement.
Of course, performance management, record keeping, regulation, inspection and scrutiny are vital because they identify where systems are not working, but in themselves they do not prove service quality.
Haringey and Mid Staffordshire senior managers and boards spent too much time distracted by more easily attainable targets, which told them they were doing well, and not enough seeing what occupied people’s minds on the front line.
It is important that frontline practitioners feel able to raise their concerns, and those of the people for whom they care, without the fear that this would harm their professional standing.
They need time and space to develop their curiosity about innovative working methods, external quality measures and sharing good practice.
In the best organisations, with robust board leadership, board members, or councillors, are engaged with the shop floor rather than relying on performance management reports.
It also seems clear that both the NHS and councils need to move away from reliance on quantitative data to seeking proof of good quality.
Health service organisations are already working hard to ensure quality leads the way they work and mechanisms such
as quality accounts will become a vital part of their board discussions.
Practical measures of these kinds will show whether people are happy and the job is being done well. But there is no magic bullet for the problems facing public bodies.
What is also needed is a questioning culture of creative scepticism where dissent is positively encouraged.
An environment where individual initiative is prized and professional standards driven relentlessly upwards is the challenge with which public service leaders must now wrestle.