HSJ has reported on the pressure on Sir David Nicholson to resign following the Francis report and the case made in his defence. Roger Kline examines both sides of the debate

Jeremy Hunt says it is “absolutely disgraceful” that no one has been held to account for the patient deaths in Mid Staffordshire. Yet the Francis report itself holds back from calling for “heads to roll” and ascribes responsibility to the “system”.

So no heads have rolled so far. But should they, and if so should it be Sir David Nicholson’s, the most important head of all?

‘One might reasonably conclude a case to answer that Sir David should have personally intervened at an earlier stage ‘

Let’s ask two questions. The first one is whether Sir David was sufficiently aware, or could reasonably have been expected to have been sufficiently aware, of the carnage in Mid Staffordshire, and have intervened earlier?

The Francis inquiry was told that he had been personally told by the Healthcare Commission about the serious concerns about Mid Staffordshire in May 2008.

A case to answer

Well before then, Professor Sir Brian Jarman’s hospital standardised mortality ratio data on the trust was in the public domain and should surely have ring alarm bells at either the strategic health authority where Sir David was chief executive or later at the Department of Health when he became chief executive.

Why didn’t it? Was it because, as he told the inquiry, “quality wasn’t the organising principle of the NHS, it wasn’t the thing that was driving us during that period”.

‘Sir David still refused to accept there was a “shame and blame culture” in the DH’

When it finally dawned on Sir David that Mid Staffordshire was a disaster he told the inquiry (his statement, paragraph 317) that the trust was “singular” rather than “systemic”, a view the inquiry counsel’s closing submission dismissed, saying thus “this seems to us to be a very dangerous attitude to take.” 

In his final submission to the earlier Bristol inquiry, the leading counsel for the DH addressed the question of whether “anyone”, as opposed to the “system,” might be accountable for what went wrong.

Mr Pirhani stated on February 9 2000 that “the Department of Health accepts that it is responsible and is accountable for any failings of the systems that were in place during the period covered by the Inquiry.”

Taken together one might reasonably conclude a case to answer that Sir David should have personally intervened decisively at an earlier stage to stop the carnage; should not have claimed Mid Staffs was an isolated example; and is (as DH chief executive) at least partly personally accountable for these catastrophic system failings.

Taking Francis forward

The second question is whether Sir David is the right person to take forward the Francis report’s recommendations?

Robert Francis accepted the evidence that an open, transparent, “just” culture is the precondition for good, safe, care; a culture in which staff are seen as an asset to be valued not just a balance sheet cost; one in which bullying is not a dominant feature. One where challenge and questions are welcomed.

That approach, alongside a more “distributed” leadership, is accepted by NHS Employers. But to be embedded at every level of the service it surely has to be modelled by top NHS leaders.

‘No man is “indispensible”. If he was then that might be another reason to ask whether he is the right man to lead a different NHS’

Such a culture is completely different to the command and control culture Sir David and the DH leadership have thrived on. Two independent reports commissioned by Lord Darzi, and witness statements to the Francis inquiry, all reported a “pervasive culture of fear” throughout the NHS and in parts of the DH, with fear among chief executives of public humiliation or losing their jobs as a prime driver for quality improvement.

Sir David still refused to accept there was a “shame and blame culture” in the DH though subsequent surveys of senior managers and staff confirmed that picture.

No one is indspensible

In defence of Sir David Nicholson, it is said he “is a caring man”, that his departure would impede implementation of the Francis recommendations and that calls for his departure are made in a “lynch mob atmosphere”.

No man is “indispensible”. If he was then that might anyway be another reason to ask whether he is the right man to lead a different NHS. The smoke and mirrors from the DH over gagging clauses in general, and Gary Walker’s case in particular, inspire no confidence that the culture of denial has changed. Accountability is not the same as scapegoating.

A wise Bristol inquiry veteran told me that if the Francis inquiry was to do better than the Kennedy inquiry and prevent further Mid Staffordshire-style disasters, then a corporate manslaughter charge against the Mid Staffordshire board, and a change of leadership at the DH were essential.

It appears the police investigation may trigger the former. Sir David Nicholson’s final act of leadership should be to ensure the latter. Such changes can’t guarantee effective change but they make it more possible. We owe nothing less to the patients who died and the staff who must work to ensure no repetition.

Roger Kline writes on the duty of care and works with Patients First, Public World and whistleblowers