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Root causes of organisational failure: look up, not down
  1. Chris Newdick
  1. School of Law, University of Reading, Reading, UK
  1. Correspondence to Professor Chris Newdick, Professor Emeritus, School of Law, University of Reading, Reading, RG67BA, UK; c.newdick{at}reading.ac.uk

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‘Organisational failure’ is central to medical ethics. In the National Health Service (NHS), we usually examine failures at hospital level. We have had around 100 hospital inquiries since the first in 1969, into Ely Hospital, Cardiff. This year, we had the Ockenden Report into Shrewsbury and Telford Hospital. Last year, we had the Outram Inquiry into West Suffolk Hospital. In 2020, the James Inquiry into Ian Paterson. And, before that, Morecombe Bay, Gosport War Memorial, Mid Staffordshire, Liverpool Community Health, Winterbourne View, Anthony Ledward, Stoke Mandeville, Bristol Royal Infirmary and so on.

As Taylor says, these reports teach us clinical failure usually has an institutional setting and that blaming individuals overlooks working ‘culture’. They have also led to: (a) new regulatory bodies to manage, investigate and improve NHS standards, (b) new codes of conduct to mandate reporting of serious accidents—backed up by the Whistle-blower’s Act and explicit statutory duties of disclosure, (c) root cause analysis to encourage consistent investigations so we can learn from reliable data and (d) new ‘Speaking Up Guardians’ and a Patient Safety Commissioner to encourage informal discussion about patient safety.

What is so surprising is how little these inquiries and reforms have achieved on the larger scale. Of course, we must understand why hospitals fail, but why are some clinicians and some NHS managers, in some circumstances, so tolerant of patient suffering? In a public service so closely identified with the Nolan Principles of Public Life, of selflessness, honesty and integrity, how can we so persistently lose sight of basic patient safety?

Let us be candid; government plays a crucial role. The all-party House of Commons, Health Committee1 highlights the failure to plan for the NHS workforce. Staff have unsustainable workloads. Waiting time targets are becoming irrelevant to those needing hospital treatment. Discharge is delayed for lack of care in the community. Ambulances are paralysed in queues outside accident and emergency units full to capacity, and patients are treated on hospital trolleys by exhausted clinicians. Twelve years of austerity leave the appearance of a government indifferent to the future and integrity of the NHS.

These problems have been accumulating for years. In 2013, the Mid Staffordshire Inquiry discussed ‘chronic staffing deficiency exacerbated by the need to meet financial targets.’2 In that case, corporate pressures to control budgets dominated clinical priorities so that insufficient nurses were required to supervise too many patients in too few wards. Today, the Morecombe Bay Inquiry and the Ockenden review represent risks that probably exist in many NHS maternity services.

The Care Quality Commission (CQC) reports that the NHS workforce gap in 2020/2021 was 115 000 full time equivalent staff (FTE).3 The Health Foundation, King’s Fund and Nuffield Trust say: “NHS shortages could grow to up to 200 000 by 2023/24, and at least 250 000 by 2030.”4 As the Health Committee says, this inevitably impacts on service quality. Nurses say that 8 in 10 shifts have insufficient staff to keep patients safe. The General Medical Council (GMC) reports that 3 in 10 doctors have seen patient care compromised. This is not just about patients. Staff are exhausted, burnt out and dreading work. Absences through anxiety, stress and depression are common. Working culture is poor. Staff retention is awful.

Government’s involvement in this process was discussed over 20 years ago by Professor Sir Ian Kennedy in the Bristol Report. As he said, governments make claims for the NHS:

which [are] not capable of being met on the resources available… Healthcare professionals have been caught between the growing disillusion of the public on the one hand and the tendency of governments to point to them as scapegoats for a failing service on the other … (Learning from Bristol, Cm 5207, 2001, 57, para 31)

NHS managers have never successfully confronted this abuse. Instead, when problems occur, as Sir Robert Francis noted, “for all the fine words about candour there lurks within the system an instinct for concealment, formulaic responses and avoidance of public criticism.”5 The Messenger Report6 found the same. Pressure from above ‘creates an institutional instinct… to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user.’ This encourages ‘bullying, blame cultures and responsibility avoidance’. Jeremy Hunt, a previous Health Secretary, said the same in a different context to the Infected Blood Inquiry: staff are ‘often terrified that if they were open about mistakes, they would get fired or not be allowed to practice anymore…’ This, he says, encourages a ‘cover-up culture’ where ‘institutions and the State close ranks around a lie’.7

NHS managers must resist this culture by following the Nolan duties. Be honest with the public. Tell the truth. Challenge government to fulfil its own statutory duty to ‘securing continuous improvement in the quality of services provided to individuals…’ (NHS Act 2006, section 1A). Start with the NHS workforce. How many nurses and beds are normally needed in a particular setting? Below what number of consultants should a unit be considered under-staffed? When should further admissions be unsafe and, if necessary, wards closed to further patients? And what levels of community care are needed for patients to be discharged properly from hospital? Make these numbers public and transparent.

We are so good at analysing hospital failure. Why are we so poor at assessing government itself? These questions should be discussed in the clinical curriculum. Volume II of the Independent Inquiry into Care Provided by Mid-Staffordshire NHS Foundation Trust should be compulsory reading. Hear what happens when patients stop being the priority. Trainees would understand the NHS as a whole system. Better still, it could foster a more constructive, less ‘captured’ framework for managers to promote a patient-centred relationship with government.

Rishi Sunak, our previous Chancellor, now describes NHS waiting times as a "national emergency." True, but the answer to the crisis of neglect is not a succession of disjointed inquiries into hospital failures.

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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