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Chris Hart: ‘Mid Staffs is not about nursing, it’s about government policy’

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.

Readers' comments (39)

  • Tiger Girl

    Yes. But it doesn't necessarily matter that francis did not overtly comment on the politics - he was excellernt at pointing out why problems happened, and either the 'culture' has to change, or the Francis report is being ignored. He has made it very hard to 'cherry pick what suits us' in isolation.

    'We’re going to have to forge alliances with others who crave positive change and make it happen.'

    Nursing needs to form an alliance with patients. An alliance at the coalface, to speak truth to power.

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  • tinkerbell

    well said. thank you.

    Management is so far removed from what is now the 'battlefield' of working on the frontline they are clueless unless we continually tell them 'this is not nursing'. It has gone beyond even 'coping' and coping is not the same as caring.

    Unless the frontline UNITE and take the lead rather than being lead we are heading towards disaster. Because those supposedly leading us either don't care or are clueless.

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  • Right, so if it's about policy, managers implement policy. So why does the report not make any recommendations that couldn't have been cut and pasted from the Bristol heart scandal over ten years ago and why have no senior people had the humanity to resign?

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  • This wouldn't have happened in those other countries where the nursing profession is stronger and wouldn't tolerate such conditions. It is about governments and the creation poisonous policies which put of financial considerations before the welfare of patients and toxic work environments. It is about the lethargic public who can't be bothered to walk to a ballot box and look what happens. But it is also about nursing. Are we going to be disproportionately blamed for Stafford and, by the looks of things, elsewhere? Absolutely.

    " 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."

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  • michael stone

    For what its worth, I agree with all of you - and I cannot provide 'acceptable' answers to Nobody's questions, unfortunately. Not only do NHS reports tend to keep highlighting the same issues, but actually most reports into most 'scandals' (whatever sphere) seem to invariably say 'The behaviour was not joined-up, the situation was under-resourced, and people were following guidance to the exclusion of using any sense at all'. My words, but I'm sure you get the idea.

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  • I would agree management are out of touch with the frontline. The Stafford crisis is a symptom of the dysfunctional and fragmented nature of the service. The foundation trust and trust system are the cause of the situation and they all should be disbanded.
    But Nursing is partially to blame we have let ourselves be pushed into this position. Our representitives don't represent us any more they are to close to management. I would sugest we should all ask our union reps to stand for election again and for them to outline how they will support us and patients over management policies.

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  • I think the answer is simple. Make Nursing Directors Matrons once more and remind them that they are NURSES first. If the managers representing nurses at Board room level do not firstly look to there core beliefs and resaon for being there ,the foot soldiers have no hope. They lost this in the 1990's and it has been down hill ever since

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  • Nursing must be one of the most complex and multifaceted jobs which exists. It is also considered one of the most stressful even with optimal working conditions. Is it therefore realistic to expect individuals trained in general systems management to understand and manage the highly complex processes involved in delivering nursing care, the resources required as well as providing support to those delivering nursing services, and especially if the latter group are not given a strong enough voice to express the needs of both their patients and their own enable them to carry out their job to the highest standards.

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  • Hear hear Anon 1.46pm.
    If you hid behind the curtain in the many endless meetings I go to, and someone asked you afterwards to guess who has what professional background, you'd struggle to work out who were the senior nurses. If we talk about patients you might, but most of the time it's all numbers and they hardly get a word in. We couldn't be less engaged with our professions if we tried. It's taken 20 odd years to get this bad and I hope to God it won't take that long to turn the tide back to common sense. I am dreading Bruce Keogh's report on the other 14 hospitals that could each be another Mid Staffs. How many more people have to die or suffer before the country says enough is enough? And Julie Bailey should get a medal.

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  • michael stone

    Anonymous | 23-Feb-2013 2:10 pm

    Did you mean to write:

    'Is it therefore (un)realistic to expect individuals trained in general systems management to understand and manage the highly complex processes involved in delivering nursing care' ?

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  • DH Agent - as if ! | 23-Feb-2013 3:28 pm

    Anonymous | 23-Feb-2013 2:10 pm

    my question was, is it realistic to expect ... etc.

    but if you write unrealistic the question is still the same, isn't it?

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  • michael stone

    Anonymous | 23-Feb-2013 4:38 pm

    Sorry, I misread your original post - your original post, which on re-reading is 100% correct (unlike my question about it).

    I suppose I was reading too quickly (my online session was nearing its end), or else just being a bit dim at the time. I'm quite good, at being a bit dim at the time.

    Nowever, your general point seems to be that nursing feedback needs to be listened to (and presumably encouraged) and I'm totally with you about some mechanism for 'bottom-up' feedback and comments about 'top-down diktats'.

    Although I support that for feedback from everyone: not just nurses, but all occupations/layers within an organisation.

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  • DH Agent - as if ! | 24-Feb-2013 12:36 pm

    Anonymous | 23-Feb-2013 4:38 pm

    That’s ok we all do it but I was perplexed as to whether or not I had expressed myself clearly? One doesn’t always have the insight to know if one is going bonkers or not!

    I thought one of our fundamental human rights was that of free expression so I am not sure why this does not apply in the NHS, as well as many other organizations. Everybody, no matter who they are, should feel free to express their concerns and have them listened to. It is also the duty of every employer and employee from top to bottom and bottom to top to act upon them if they can reasonably do so. This is why one is employed and paid, and is part of the job. It seems that the professional codes of conduct of the various groups of healthcare workers are not being respected by their employers yet they will not hesitate to report them to their regulatory bodies for any infraction even if this is beyond the employees’ control.

    I just had a quick look at our rights as EU and world citizens and although it states everybody has the right to free expression, it does not actually mention the right to be heard, which one often hears said (no pun intended - am just in a rush). The problem here is you can thus express yourself in any manner you deem fit, but how can you be sure you are being heard or that anybody is listening to you when you cannot actually force anybody to listen! I guess you just stand over them and demand feedback to make sure you have been understood, taken seriously and any suggestions or complaints you make will be acted upon if appropriate, and you do not leave until you have ensured that they haven't binned any written documentation! Maybe sending feedback electronically is more indelible but then how can you be sure the person concerned will see it or even read it?

    I still believe my pigeons are more reliable!

    Have to rush, hope my post is clear but of course you have every "right" to question it and I will make every endeavour to see and read it!

    (2000/C 364/01)

    Article 6
    Right to liberty and security

    Article 11
    Freedom of expression and information
    1. Everyone has the right to freedom of expression. This right shall include freedom to hold opinions
    and to receive and impart information and ideas without interference by public authority and regardless
    of frontiers.
    2. The freedom and pluralism of the media shall be respected.

    Article 41
    Right to good administration
    1. Every person has the right to have his or her affairs handled impartially, fairly and within a
    reasonable time by the institutions and bodies of the Union.
    2. This right includes:
    . the right of every person to be heard, before any individual measure which would affect him or her
    adversely is taken;

    Article 42
    Right of access to documents
    Any citizen of the Union, and any natural or legal person residing or having its registered office in a
    Member State, has a right of access to European Parliament, Council and Commission documents.

    The Universal Declaration of Human Rights
    Article 19.
    • Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.

    From the UN News Centre
    On Human Rights Day, UN officials highlight how every voice counts
    10 December 2012 – United Nations officials today marked Human Rights Day by declaring that everyone has the right to be heard and to shape the decisions that affect their lives and communities.
    “International law is clear: No matter who you are, or where you live, your voice counts,” Secretary-General Ban Ki-moon said in his message for the Day, observed annually on 10 December. “On this Day, let us unite to defend your right to make it heard.”

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  • tinkerbell

    Anonymous | 24-Feb-2013 1:46 pm

    DH Agent - as if ! | 24-Feb-2013 12:36 pm

    Anonymous | 23-Feb-2013 4:38 pm
    One doesn’t always have the insight to know if one is going bonkers or not!

    So true, so long as we can still ask that question then hopefully not. The thin line.

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  • tinkerbell | 24-Feb-2013 2:05 pm

    Scribo ergo sum!

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  • Tinkerbell

    DH Agent

    did you see that many of the public were against GM Food because they didn't want food with genes in it!

    Mentioned by Sir Paul Nurse, President of the Royal Society, Nobel Peace Prize for work in Physiology in 2001, in his brilliant lecture at Melbourne University

    Paul Nurse

    Making science work - The Science Show - ABC Radio National (Australian Broadcasting Corporation).htm

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  • Jasmine: Look, I am innocent. Why doesn't anybody believe me? There were other people in the operating theatre. It was the surgeon's fault.

    Matisse: And do you think they will actually speak up? Seriously, how many nurses do you see actually speaking up and complaining about conditions here? Too many patients, too many mistakes made in theatre. How do you think I have -managed to survive? What's the most important thing in healthcare?

    Jasmine: The patients?

    Matisse: Patients? Patients? Who cares about them? Would we have Mid-Staffs if people cared about them? Jasmine the most important thing in healthcare at the moment are the budgets and the targets. Nothing else matters. Why do you think we have rubbish support? Why do you think we have less nurses? Everybody knows you're innocent but you're just a nurse and have no power. Yes, you're just a nurse to all the management here. They have no compulsion to see the truth especially if they know the surgeon mucked up the operation. Its easy to get rid of a nurse then it is a surgeon who is friends with the CEO here.

    Jasmine: Its politics! The management are playing politics with lives here! Supposing if the public knew?

    Matisse: But the public don't know, do they? They have no idea what goes on here, and do they really care?

    Jasmine: Supposing if we told them what is going on? How many patients are in awful conditions because we cannot care for them?

    Matisse: Oh, so you want to put your head above the parapet? You actually want to complain? You'll get shot. They'll get a gagging order on you and then they'll maul you. But remember we do have the 6Cs!

    From my play

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  • tinkerbell

    Somewhere on the HIDDEN 'risk register' of the NHS reforms there must have been a risk highlighted that these savings would cost lives

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  • Tinkerbell

    Hey, since I was on to Human Rights earlier on, doesn't the Right to Freedom of Information Act give the right to public consultation of the 'risk register'

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  • tinkerbell

    Anonymous | 24-Feb-2013 6:11 pm

    they ignored a court ruling apparently that they should publish it.

    I can't find anything to date to say whether it has since been published or not. Too late now, it's a done deal and it stinks that they railroaded it all through and ignored the law of the land when it suited them.

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