Robert Francis QC has criticised elements of the “culture” of the NHS and Department of Health, including overly tough performance management.
His report highlights problems with the enforcement of targets. It says that, although they are not always bad, they should be “expressly balanced by provision of qualifications to allow: patient safety and wellbeing to remain the priority… and restriction of suggestions of adverse career consequences to cases of misconduct or serious incompetence”.
The report says there is not a “bullying” culture at the DH.
Mr Francis identifies across the system “a culture focused on doing the system’s business – not that of the patients”, “an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern” and “standards and methods of measuring compliance which did not focus on the effect of a service on patients”.
Mr Francis said one of his “essential aims” was to “foster a common culture shared by all in the service of putting the patient first”. This could be achieved, he said, by developing the NHS constitution and use of it; by developing clearer agreed quality standards; and by making staff responsibilities clearer.
He said of the NHS: “The common culture of caring requires a displacement of a culture of fear with a culture of openness, honesty and transparency, where the only fear is the failure to uphold the fundamental standards and the caring culture.”
And he said of the DH: “It has overseen a system of performance management and regulation that has, throughout the structure, relied in part on the assumption that other parts were working well, leading to a reduction in vigilance in relation to their own responsibilities.”
The report said: “The evidence before the inquiry does not justify a conclusion that there is in fact a culture within the DH that could properly be described as one of bullying.
“What the evidence does establish is that, at times, quite proper decisions and directives emanating from the DH have either been interpreted further down the hierarchy as bullying, or resulted in being applied inappropriately at local level, and not as intended, in an oppressive manner. It is not the intent that is in question, but the unintended consequences and perceptions of others as a reaction to the DH’s requirements.”
With specific reference to performance management and targets, it said: “It is important to make clear that it is not suggested that properly designed targets, appropriately monitored, cannot provide considerable benefit to patients and serve a useful purpose.
“Nevertheless, steps have to be taken to guard against the possibility that some providers will strive to meet targets at the expense of delivering safe and effective care to patients and this can take the form of inappropriate bullying, as occurred at this trust.
“So far as the DH itself – and its operational arms such as the NHS Commissioning Board – is concerned, it must ensure that performance requirements are always expressly balanced by provision of qualifications to allow: patient safety and wellbeing to remain the priority; resources and support that enable the requirements to be met; and restriction of suggestions of adverse career consequences to cases of misconduct or serious incompetence.”