Published: 13/05/2004, Volume II4, No. 5905 Page 16 17

A police investigation into allegations of patient abuse lifted the lid on outdated hierarchies at a former trust. An external review was released last week, prompting intense self-scrutiny as the new trust strives to transform its culture

Trusts employ thousands of staff and are involved in hundreds of thousands of individual patient contacts each year. Their staff are generally well intentioned, competent and respond positively to responsibility and trust.However, occasionally they do not, and even more rarely a bad apple can begin to affect a whole barrel.

In addition to my day job as an academic, I chair Birmingham and Solihull Mental Health trust, which has a catchment population of well over a million people.We work from about 90 sites, dealing with five commissioning organisations and two local authorities, and have recently undergone a merger that brought together two very different clinical and managerial cultures.

The last 20 years have seen a truly radical shift from more 'custodial'models of care to the therapeutic environments at the core of effective modern mental healthcare. The changes required in staff values and belief systems to make such a move should not be underestimated.

Most of those involved in delivering care to mentally ill patients have coped admirably with this change, but a small number have found it difficult to let go of the strict, almost military, hierarchies that prevailed in the old 'bins'. To these traditionalists, the notion of challenge or discussion seemed threatening, and clinical governance was an alien idea.

In one of our antecedent trusts, an autonomous, non-corporate culture emerged in which one or two senior members of staff ran their fiefdom in a way that brooked no argument.

Accountability was opaque and there was a reluctance to accept direct responsibility for actions taken.Much of the ward culture was driven by strong individual personalities, and in the worst cases patient care took second place to staff interests. The links between this ward culture and trust senior management were not as well established as they should have been; the board was seen as 'them', a separate part of the organisation that could threaten the autonomy of this small sub-culture.

Matters came to a head in early 2002. It transpired that an elderly inpatient had been sexually abused; their death from a brain tumour provoked a flurry of activity, and some time later, charges were made against a member of staff. They were subsequently found not guilty when the case came to court in early 2003, just as the new Birmingham and Solihull Mental Health trust was being formed.

However, it soon became apparent that this was not an isolated incident. This realisation prompted urgent discussions between Birmingham and the Black Country strategic health authority, the newly merged trust and the Commission for Health Improvement. As a result, the SHA set up an independent committee of inquiry led by an external chair.

Resourced by independent consultants, supported by members of staff and guided by an external, uninvolved steering committee, the Avonside inquiry (named after the ward involved) analysed all the events that had taken place on the unit, interviewed the vast majority of the key players and involved the affected patients and their families. Its report was published last week.

My first observation in reviewing the report's findings would be that all change takes time, and that for significant organisational and cultural change to truly embed itself requires huge effort. In the NHS we have always been more comfortable dealing with immediate problems than in properly sorting out the underlying issues.

If staff at the existing trust had been helped 15 years ago to understand the implications of the organisational changes taking place, the hierarchies that allowed unreasonable authority to persist could have been defused.

Because they were not, it was extremely difficult for anyone to blow the whistle.

Like many other large organisations, the NHS finds it hard to create the climate for appropriate whistleblowing.

Complaints and misgivings are either ignored or turned into full-scale disciplinary procedures without much sense of perspective, often making the whistleblower's normal life impossible to maintain.

This issue links very closely to that of clinical governance in its broadest sense. There is a tension between the 'blame frame' that so bedevils the NHS and simply turning a blind eye to problems, taking a 'there but for the grace of God' attitude. Striking the correct balance is one of the key tasks of clinical governance, and we have yet to get it right.

Then there is the issue of board accountability. The purpose of non-executive directors (NEDs) is to support their organisation and to provide constructive challenge to their executive colleagues. In the case of Avonside, creating a balance between these two seems to have been impossible.

NEDs' involvement is always part-time; the attention they can pay to any particular piece of work is determined with their executive counterparts. But if NEDs cannot take for granted the accuracy and completeness of the information given to them, a climate of mistrust is likely to be generated and corporate working becomes impossible.

This is what seems to have happened at Avonside, as events in the darker corners of the old trust were never apparent to the board.

The relationship between the executive and NEDs lies at the very centre of public sector management. Psychology and common sense tell us that people respond better to a climate of trust than mistrust.

In today's risk-averse NHS, the temptation is to go for 'earned autonomy', which may be safer, but it risks alienating and disempowering the entire workforce.

Disempowerment goes beyond management. The events at Avonside have impacted on other members of staff at the unit. All have been functioning under a cloud of uncertainty and suspicion, and for the vast majority who are dedicated and keen this has caused much distress. Feelings of self doubt, self recrimination, almost a sense of corporate guilt, have all been noted and much constructive work will be required to build up self-esteem and morale.

At a more practical level, the interface between police activity and NHS disciplinary processes requires better co-ordination.

When a ward crisis comes to a head, the first action of trust management is often to suspend the member of staff under suspicion, but this obviously alerts that person, which may muddy the evidence trail as far as any police investigation is concerned.

At a basic level, the concern of NHS staff is to ensure the safety and care of their patients, while the objectives of the police are to identify and convict any lawbreakers. These different aims may conflict with each other.

So what of the future? The recommendations of the Avonside report are being fully implemented and the new trust has also instituted a thorough, organisation-wide review of the ways in which we all work.

But it is at the strategic and philosophical level that the report must have its maximum impact: changing cultures, motivating people and promoting an atmosphere of responsibility and proactivity in the care of patients are all highly complex tasks that cannot be achieved by diktat or simple rules.

The focus of the new organisation must be to work with our staff and to take a strategic, long-term view of all aspects of our interaction with our users. Only by thinking holistically, and by accepting that maturity takes time and effort to develop properly, can the phoenix of the Avonside ward rise from its ashes and teach the rest of the NHS lessons from which we would all benefit.

Jonathan Shapiro is chair of Birmingham and Solihull Mental Health trust and senior fellow at Birmingham University health services management centre.