The government response to the terrible failings of the Mid Staffordshire hospital system is a remarkable document.
It may even become a classic state paper. It is certainly an unusual one. Busy media organisations duly reported the various corrective measures that were announced in its wake – among them the appointment of a chief inspector of hospitals, the barring of bad managers from further senior jobs and a new system for rating hospitals.
They didn’t have time or space to say anything about the evangelical language. The key to its style is the observation that working in health and care is “inherently emotionally demanding”. Likewise, the document implicitly calls for an emotional response. It stresses the “core humanitarian values” of the NHS.
The tone is set early on with the comment that what happened at the Mid Staffordshire NHS Trust was the development of a toxic culture that fostered the “normalisation of cruelty”, an unlikely phrase in a government document, yet a fair description of what many patients endured. The public inquiry, chaired by Robert Francis QC, revealed what the family of a 96-year-old patient discovered: “There were people walking past. Mum was in bed with the cot sides up and she hadn’t got a stitch of clothing on. I mean, she would have been horrified. She was completely naked ... covered in faeces ... It would have been there a long time, it wasn’t new.”
As a consequence, Jeremy Hunt, the Secretary of State for Health, writes in his forward that “every individual, every team and every organisation needs to reflect with openness and humility about how they use the lessons from what happened ”. This evocation of humility is not common in Whitehall. Then if you turn to the end of the document you find that even the staff of the Department of Health itself must “model the same caring values and behaviours that we seek to foster across the wider system”. Within four years, every civil servant in the department will have “sustained and meaningful experience of the frontline”. And this is all of a piece with the new requirement that every student who seeks NHS funding for a nursing degree should first serve up to a year as a healthcare assistant in order to promote frontline caring experience and values.
One way to analyse the full scope of the Government’s response is to use a distinction common in international affairs between coercive force and soft power. The measures announced yesterday, such as rigorous hospital inspections, were the former. This hard power is designed to stop the development of any Mid Staffordshire tendencies in the making. But much of the document is also concerned with soft power. The reason is that what is being attempted is changing the culture of an organisation that employs more than a million people in England alone and is now 65 years old. The scale of this task explains the religious fervour of the document.
The decision that the “common values and cultural attributes that we seek to foster across the NHS should be set out in the NHS Constitution” is an example of soft power. More striking still is the inclusion of a “statement of common purpose” by 14 leaders of the service along with an invitation to organisations in the system “to join us in signing up”. The Permanent Secretary at the Department of Health and the chairs of the Care Quality Commission, the General Medical Council, the NHS Commissioning Board, the NHS Confederation and NHS Employers, and the Nursing and Midwifery Council are some of the signatories. Curiously the name of Sir David Nicholson, chief executive of the NHS, is missing.
Among the pledges contained in the statement of common purpose, a number exemplify the humility called for by Mr Hunt. “We apologise to every individual affected by this deeply disturbing and tragic failing in a service that means so much to us all… We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves.” And finally this extraordinary promise: “Changing ourselves, our behaviour, individually and institutionally, is difficult, but we pledge to do so.”
The authors realise that their document is not going to change cultures in wards. “What matters is whether teams are inspired to own and live the values set out in the Constitution.” Own and live the values! There follow a number of measures to help this process.
A wealth of evidence shows that the key to providing safe, effective and compassionate care is supporting and valuing staff. In other words the rule is: look after your staff well and they will look after the patients well. At the same time the response argues that leaders need time to lead, and staff need time to care, unconstrained by a culture of bureaucratic compliance with national regulations. These are wise thoughts. The cruelty of Mid Staffordshire was the result of setting a multitude of targets for staff and then chasing them to achieve them.
Treat staff well and give them time – that should produce the sympathetic care that helps patients to recover or at least endure their final illness peacefully. The authors of this document have grasped both these things. That is why this response is so remarkable.