Mid Staffs and the NHS: church in need of reformation

http://www.guardian.co.uk/commentisfree/2013/feb/06/mid-staffs-nhs-reformation-editorial

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The appalling suffering and needless deaths of hundreds of patients in Stafford hospital are a wake-up call for the National Health Service. Although the NHS has been for the public an almost spiritual preoccupation, summed up by Nigel Lawson's quip that it was the closest we have to a national religion these days, Robert Francis QC's heretical truth among 290 recommendations is that in parts of the health service, it is the culture that kills rather than cures. This may be today's deadly malaise but it is not a new one. Indeed, when another QC, one Geoffrey Howe, led an inquiry in 1967 into serious allegations of abuse and ill-treatment of vulnerable, long-stay patients at the Ely hospital in Cardiff, he concluded that at fault lay "poor clinical leadership, an isolative and inward-looking culture, inadequate management structures and systems".

Plus ça change, you might think. This would be a mistaken view. All too often in the past, the issue was the clubbiness of the medical profession – exemplified by the closed culture exposed by the public inquiry into Bristol child heart surgery, where doctors put their interests above their patients'. What Francis has done is expose a new unhealthy, managerially obsessive culture of targets, money and incentives. In the case of Mid Staffs, it led to a "culture of self promotion rather than critical analysis and openness". This was not challenged by consultants who "kept their head down" and nurses who "tolerated" poor performance. Running through the Francis report is a call for a new professionalism with a return to the sense of vocation, mission and purpose – where the patients are put first in "a caring and compassionate way". There is little to argue with in these words.

Francis's x-ray of the NHS highlights a chain of failure – in hospitals, in layers of health service oversight, by regulators and by professional bodies. There is also an important difference between today's NHS and the one which Stafford hospital experienced: money. In these times of austerity the health service is being asked to save money rather than spend it.

In responding to the report, David Cameron adopted a measured tone and asked the probing question – and was right to ask, given the scale of systemic failure – why has not one person been prosecuted. It could have hardly escaped his notice that just two days ago a former director of nursing at Mid Staffordshire Foundation Trust, there at the time of the crisis, was cleared of any wrong-doing by the professional standards bodies for nurses. Little wonder that the coalition's secretary of state for health will be writing to the medical regulators in the coming days asking why professionals are still allowed to work despite their time at Stafford hospital. There is a lingering suspicion that the government will seek to use the Francis report as cover to further its own agenda – and there were unfortunately signs of this in Mr Cameron's attempt to link nurses' pay to quality of care.

To open up the health service, Francis wants to refound the NHS on principles of transparency, candour and openness and put the patient's voice at the heart of the service. Again, the coalition may seek to put this report to the service of a more ideological project – reforming the NHS on the lines of choice and competition. But this is a necessary risk. Francis's call for criminal sanctions for those that cause harm and for doctors and managers to have a duty to reveal instances of poor care are necessary steps to make profound change in the NHS.

While the report's only big structural change – the creation of a super-regulator – may end up discarded in the Whitehall battles ahead, there is merit in revisiting this argument given the failures of the system. Francis has been thinking about healthcare and Mid Staffs for three-and-a-half years. This is his second inquiry into the scandal. It is a tribute to his powers of cross-examination and stamina that he's probably won few friends in the NHS. Questioning a religion is never popular. However, history has proved that a reformation saves a church.