The Francis report describes in horrific detail the impact of political change without ever acknowledging the politics behind the scandal, says Chris Hart
In the wake of the Francis report, every nurse should be issued with a wide-brimmed hat and a gas mask. We are about to be buried under a ton of hypocrisy and the stench will soon be unbearable.
Politicians from every party will be voicing outrage. Senior civil servants and high-ranking NHS personnel will be full of apologies. Everyone will be talking of further “reforms” and how this must never be allowed to happen again. We must listen to patients, we must listen to carers, we must be open and transparent and so on.
Meanwhile, the context, politics and economic conditions that created the Mid Staffordshire Foundation Trust scandal remain – making up a festering, growing sore at the core of our healthcare system.
Top-down targets must still be met locally. If the staff at local levels have no ownership of those targets and don’t see their rationale or agree with them, bullying becomes an inevitable managerial response.
‘If Mid Staffs is never to happen again, the entire framework of the NHS would need to be change’
Once bullying enters the managerial culture, it spreads like a lethal virus and is almost impossible to contain. When nurses are bullied, they inevitably become frightened and stressed. They then disengage from everything else stressful, including patient care. The emotional labour required of nurses – far harder than the considerable physical demands of the job and the part that creates compassion, caring and the curiosity necessary to really hear patients and respond to their needs – becomes a casualty.
Many have asked why so few nurses attempted to tell anyone what was happening at Mid Staffs, particularly as trusts have a whistleblowers’ charter. Of course, there was a time when nurses were very good at blowing the whistle on bad practice. They became so good at challenging bad management or attempts to subjugate them that politicians and managers had enough of it. Gagging orders became the routine response. Union influence was broken. The way Graham Pink’s career was destroyed was a lesson to everyone.
Charters were often used to tie up whistleblowers in bureaucracy and give managers ample opportunity to silence them. It’s a bit like organisations trumpeting “our values” or politicians singing out “we’re all in this together”. In these days of Orwellian doublespeak, one knows immediately our values are about to be trampled, and those at the bottom of the pile are on their own.
In such an environment, nurses have long lost the fragile skill of saying “No”. No, we won’t be treated like second-class citizens. No, we won’t agree to cuts that harm patients. No, we won’t sit back and watch standards slip. No, we won’t accept that things have to be this bad. Once that happens, we find ourselves seeing bad things happen, then doing them, then having to rationalise our behaviour until it’s either not our fault or we’re so far removed from what we’re doing we don’t have to think about it. This isn’t unique to Mid Staffs. It’s true across the NHS.
Senior nurses are routinely being bullied. NHS chief executive David Nicholson’s threat that directors of nursing must personally sign up to every single cut and loss of service in their trust was the most overt example of some of the things going on behind closed doors. The implication is clear: if you don’t do as you’re told or as we want, you’ll be out of the door. And it filters all the way down to nurses working directly with patients.
There is a great deal to be commended in the Francis report but, essentially, it describes in horrific detail the impact of a hurricane without ever acknowledging there was a hurricane. And the hurricane was the political change in the overall management of the NHS from the mid 1980s onwards.
Ultimately, Mid Staffs is not about nursing. It is not even about management. There should be no mistake – Mid Staffs was the result of New Labour policies, a direct consequence of Alan Milburn’s target-driven management, his “reforms” and demand that foundation trusts be established to break up a national service, ushered in mendaciously by John Reid in the teeth of fierce opposition. But the true genesis of that policy can be traced back to the Conservatives’ introduction of general management in the mid 1980s and Ken Clarke’s white paper that introduced the internal market a few years later.
The report completely ignores the fact that the coalition’s health service reorganisation, coupled with never-before seen levels of funding reductions, is hitting what’s left of a national service like a tsunami. Money isn’t the only solution, but removing it as the coalition has, while demanding more and better services, makes matters dramatically worse. And of course, this feeds the dysfunctional culture behind the horror of Mid Staffs.
If Mid Staffs is never to happen again, the entire framework of the NHS would need to be changed. Top-down targets have to end. Competition has to end. A new form of localised management has to involve staff and the community served by the healthcare organisation – and not in the fatuous, tokenistic way they are in foundation trusts. Organisations have to be significantly smaller if they are to be truly responsive to their local communities, as well as being more easily and effectively managed, with systems of shared governance. There will always be tension between central and local organisations in a national health service. But greater local democracy can allow a more facilitative and enabling approach from a Department of Health that sets the goal of genuine partnership.
The Royal College of Nursing and Unison must restore local organisation that can truly represent nurses, help give them a voice again and hold management to account. There has to be an end to the lie that one of the world’s most affluent economies cannot afford adequate levels of funding for healthcare.
Responsibility ultimately lies with the hospitals and the staff on the ground, said Mike Farrar, chief executive of the NHS Confederation, on BBC’s Newsnight. In a way, he’s right. Certainly, it’s highly unlikely that anyone who made crucial decisions that contributed to this terrible outrage will be held to account.
But any nurses sickened by what they read in the Francis report, who want to see change that gives nursing its proper place in the healthcare hierarchy and allows us to provide the necessary care for patients, are going to have to realise no one will deliver it for us. We’re going to have to forge alliances with others who crave positive change and make it happen. Otherwise, pull that hat tight over your head and keep the gas mask on.
Chris Hart is consultant nurse in forensic and intensive care nursing, South West London & St George’s Mental Health NHS Trust and principal lecturer, Kingston & St George’s University of London.